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CLINIC PHARMACY
CAH451313-01 FISHER COUNTY HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
FISHER COUNTY HOSPITAL DISTRICT
Subdivision Name
Roby Rural Health Clinic
Type
Critical Access Hospital
340B ID
CAH451313-01
Entity Address
117 E. North 1st St
Roby, TX 79543
Medicare Provider Number
451313
Outpatient Facility Provider Number
Participating Start Date
4/1/2017
Last Recertification Date
8/25/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
CLINIC PHARMACY
Pharmacy Address
774 STATE HIGHWAY 70 N
ROTAN, TX 79546-6918
Pharmacy Comments
Contract Details
Approval Date
7/8/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Leanne Martinez, CEO
(325) 735-2256 Ext: 284
Contract Pharmacy Representative
Toutbon, LLC
Mikel McWilliams, Owner
(325) 573-7582
Signed By Date
7/8/2019
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