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MARKET STREET PHARMACY #675
DSH450132 MEDICAL CENTER HOSPITAL
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Covered Entity Details
Entity Name
MEDICAL CENTER HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450132
Entity Address
500 WEST 4TH ST.
ODESSA, TX 79761-5001
Medicare Provider Number
450132
Participating Start Date
4/1/1998
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
MARKET STREET PHARMACY #675
Pharmacy Address
4950 E 42ND STREET
ODESSA, TX 79762
Pharmacy Comments
Contract Details
Approval Date
1/10/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/24/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matt D Collins, Vice President of Operations
(432) 640-2445
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/10/2020
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