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HEB PHARMACY #382
DSH450132 MEDICAL CENTER HOSPITAL
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Covered Entity Details
Entity Name
MEDICAL CENTER HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450132
Entity Address
500 WEST 4TH ST.
ODESSA, TX 79761-5001
Medicare Provider Number
450132
Participating Start Date
4/1/1998
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #382
Pharmacy Address
3325 WEST WADLEY
MIDLAND, TX 79707
Pharmacy Comments
Contract Details
Approval Date
10/13/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matt D Collins, Vice President of Operations
(432) 640-2445
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
10/13/2020
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