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AMERITA
RRC450032-00 GOOD SHEPHERD MEDICAL CENTER
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Covered Entity Details
Entity Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC450032-00
Entity Address
811 SOUTH WASHINGTON
MARSHALL, TX 75670
Medicare Provider Number
450032
Participating Start Date
11/30/2020
Last Recertification Date
8/18/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
AMERITA
Pharmacy Address
CENTRAL LINE INFUSION DALLAS
8080 TRISTAR DR STE 120
IRVING, TX 75063-2823
Pharmacy Comments
Contract Details
Approval Date
11/3/2020
Contract Begin Date
12/2/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael Cheek, CFO
(903) 315-1814
Contract Pharmacy Representative
Amerita
Daniel Van Valkenburg, Director 340B Program
(810) 434-2710
Signed By Date
10/9/2020
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