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WALGREEN CO.
PED453302-00 CHILDREN'S MEDICAL CENTER DALLAS
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Covered Entity Details
Entity Name
CHILDREN'S MEDICAL CENTER DALLAS
Subdivision Name
Type
Children's Hospital
340B ID
PED453302-00
Entity Address
1935 MEDICAL DISTRICT DRIVE
DALLAS, TX 75235
Medicare Provider Number
453302
Participating Start Date
4/1/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #21239
3217 MONTROSE BLVD STE 120
HOUSTON, TX 77006
Pharmacy Comments
Contract Details
Approval Date
7/13/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/13/2020
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