Contract Pharmacy Details

BRIOVARX
DSH450723 METHODIST CHARLTON MEDICAL CENTER

Covered Entity Details

Entity Name

METHODIST CHARLTON MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH450723

Entity Address

3500 WEST WHEATLAND ROAD
DALLAS, TX 75237-3460

Medicare Provider Number

450723

Participating Start Date

7/1/2005

Last Recertification Date

9/4/2024

Pharmacy Details

Pharmacy Name

BRIOVARX

Pharmacy Address

BRIOVARX OF LOUISIANA, LLC DBA BRIOVARX
1737-A SAM HOUSTON JONES PARKWAY
LAKE CHARLES, LA 70611

Pharmacy Comments

Contract Details

Approval Date

7/15/2019

Contract Begin Date

10/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/7/2020
Pharmacy closed

Contacts

Covered Entity Signing Official

Jon T Albrecht, Corporate VP, Chief Pharmacy Officer
(214) 947-2504

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

7/15/2019

340B Drug Pricing Program Database