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OMNICARE OF FORT WORTH
DSH450723 METHODIST CHARLTON MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST CHARLTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450723
Entity Address
3500 WEST WHEATLAND ROAD
DALLAS, TX 75237-3460
Medicare Provider Number
450723
Participating Start Date
7/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OMNICARE OF FORT WORTH
Pharmacy Address
14450 TRINITY BLVD, SUITE 200
FORT WORTH, TX 76155
Pharmacy Comments
Contract Details
Approval Date
10/5/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jon T Albrecht, Corporate VP, Chief Pharmacy Officer
(214) 947-2504
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/5/2020
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