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CYSTIC FIBROSIS SERVICES, LLC
PED453306-03 Methodist Children's Hospital d/b/a Covenant Children's Hospital
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Covered Entity Details
Entity Name
Methodist Children's Hospital d/b/a Covenant Children's Hospital
Subdivision Name
Pediatric Oncology Clinic - Pediatric Oncology Clinic
Type
Children's Hospital
340B ID
PED453306-03
Entity Address
4102 24th St.
300
Lubbock, TX 79410
Medicare Provider Number
453306
Outpatient Facility Provider Number
Participating Start Date
1/1/2018
Last Recertification Date
8/25/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Grigson, CFO
(806) 725-0598
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/13/2020
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