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WALGREEN CO.
PED453302-00 CHILDREN'S MEDICAL CENTER DALLAS
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Covered Entity Details
Entity Name
CHILDREN'S MEDICAL CENTER DALLAS
Subdivision Name
Type
Children's Hospital
340B ID
PED453302-00
Entity Address
1935 MEDICAL DISTRICT DRIVE
DALLAS, TX 75235
Medicare Provider Number
453302
Participating Start Date
4/1/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #12292
7255 COIT RD.
FRISCO, TX 75035
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Contract Pharmacy Representative
Walgreens
Lisa Villarreal, Analyst, 340B Operations
(847) 964-6183
Signed By Date
7/12/2019
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