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CRYSTAL CITY PHARMACY, LLC
CAH451390-00 DIMMIT REGIONAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
DIMMIT REGIONAL HOSPITAL DISTRICT
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451390-00
Entity Address
704 HOSPITAL DRIVE
CARRIZO SPRINGS, TX 78834
Medicare Provider Number
451390
Participating Start Date
10/1/2020
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
CRYSTAL CITY PHARMACY, LLC
Pharmacy Address
1313 VETERANS AVE
SUITE I
CRYSTAL CITY, TX 78839
Pharmacy Comments
Contract Details
Approval Date
8/27/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John A Graves, CEO
(830) 876-2426
Contract Pharmacy Representative
Crystal City Pharmacy
Prem Kalidindi, Manager
(830) 255-2201
Signed By Date
7/15/2020
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