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BAYLOR SCOTT & WHITE PHARMACY #108
DSH450079M BAYLOR MEDICAL CENTER AT IRVING
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Covered Entity Details
Entity Name
BAYLOR MEDICAL CENTER AT IRVING
Subdivision Name
BAYLOR SCOTT & WHITE COMPREHENSIVE - Wound Care
Type
Disproportionate Share Hospital
340B ID
DSH450079M
Entity Address
400 W INTERSTATE 635 FWY, STE 130
IRVING, TX 75063-3700
Medicare Provider Number
450079
Outpatient Facility Provider Number
Participating Start Date
7/1/2019
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
BAYLOR SCOTT & WHITE PHARMACY #108
Pharmacy Address
BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,
1901 N MACARTHUR BLVD STE 1001
IRVING, TX 75061
Pharmacy Comments
Contract Details
Approval Date
6/13/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CINDY K. SCHAMP, PRESIDENT
(972) 990-8102
Contract Pharmacy Representative
BSWH
Gary Green, Pharmacy Director
(469) 939-5291
Signed By Date
4/18/2019
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