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FIRST PHARMACY PAVILION
PED453316-03 Children’s Medical Center Plano
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Covered Entity Details
Entity Name
Children’s Medical Center Plano
Subdivision Name
Children's Health Specialty Center Plano Campus / Pulmonary Practice
Type
Children's Hospital
340B ID
PED453316-03
Entity Address
7609 Preston Road
P1100
Plano, TX 75024-3214
Medicare Provider Number
453316
Outpatient Facility Provider Number
Participating Start Date
4/1/2017
Last Recertification Date
9/2/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
FIRST PHARMACY PAVILION
Pharmacy Address
CHILDREN'S HEALTH SYSTEMS OF TEXAS
2350 N STEMMONS FWY # F1510
DALLAS, TX 75207
Pharmacy Comments
Contract Details
Approval Date
1/2/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Contract Pharmacy Representative
Children's Medical Center Dallas
David LaVecchia, Retail Pharmacy Manager
(214) 456-3212
Signed By Date
1/2/2019
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