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COVENANT HEALTH PHARMACY
PED453306-08 Methodist Children's Hospital d/b/a Covenant Children's Hospital
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Covered Entity Details
Entity Name
Methodist Children's Hospital d/b/a Covenant Children's Hospital
Subdivision Name
Radiation Therapy - Radiation Therapy
Type
Children's Hospital
340B ID
PED453306-08
Entity Address
4101 22nd Place
Lubbock, TX 79410
Medicare Provider Number
453306
Outpatient Facility Provider Number
Participating Start Date
1/1/2018
Last Recertification Date
8/25/2024
Pharmacy Details
Pharmacy Name
COVENANT HEALTH PHARMACY
Pharmacy Address
3615 19TH ST FL MS 1081
LUBBOCK, TX 79410-1203
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Grigson, CFO
(806) 725-0598
Contract Pharmacy Representative
Covenant Medical Center
Elise Johnson, Pharmacy Manager
(806) 725-7979
Signed By Date
7/12/2019
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