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AMERITA
DSH450032 GOOD SHEPHERD MEDICAL CENTER
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Covered Entity Details
Entity Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450032
Entity Address
700 E. MARSHALL AVENUE
LONGVIEW, TX 75601
Medicare Provider Number
450032
Participating Start Date
7/1/2022
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
AMERITA
Pharmacy Address
CENTRAL LINE INFUSION DALLAS
8080 TRISTAR DR STE 120
IRVING, TX 75063-2823
Pharmacy Comments
Contract Details
Approval Date
10/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael Cheek, CFO
(903) 315-1814
Contract Pharmacy Representative
Amerita, Inc.
Dan Van Valkenburg, Director, 340B Program
(810) 434-2710
Signed By Date
10/10/2019
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