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SUPER ONE PHARMACY #625
CHC26190-00 TYLER FAMILY CIRCLE OF CARE
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Covered Entity Details
Entity Name
TYLER FAMILY CIRCLE OF CARE
Subdivision Name
Tyler Family Circle of Care - Pediatric Clinic
Type
HRSA-Funded Health Center
340B ID
CHC26190-00
Entity Address
214 E. Houston
Tyler, TX 75702-8131
Grant Number
H80CS26190
Participating Start Date
1/1/2016
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
SUPER ONE PHARMACY #625
Pharmacy Address
113 NORTH NW LOOP 323
TYLER, TX 75702
Pharmacy Comments
Contract Details
Approval Date
10/6/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/9/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Erich Koch, Chief Financial Officer
(903) 525-7497
Contract Pharmacy Representative
Brookshires
W Mark Sullivan, Pharmacy Operations
(903) 877-6852
Signed By Date
10/6/2019
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