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CVS PHARMACY, INC.
DSH450054 SCOTT AND WHITE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SCOTT AND WHITE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450054
Entity Address
2401 S 31ST ST
TEMPLE, TX 76508
Medicare Provider Number
450054
Participating Start Date
4/1/2006
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
DBA CVS/PHARMACY #10818
820 S 5TH ST.
WACO, TX 76706
Pharmacy Comments
Contract Details
Approval Date
5/18/2020
Contract Begin Date
5/18/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shahin Motakef, CEO
(254) 724-6583
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
5/18/2020
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