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CVS PHARMACY, INC.
DSH450867 Ascension Seton d/b/a Ascension Seton Northwest
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Covered Entity Details
Entity Name
Ascension Seton d/b/a Ascension Seton Northwest
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450867
Entity Address
11113 RESEARCH BLVD
AUSTIN, TX 78759-5297
Medicare Provider Number
450867
Participating Start Date
7/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
DBA: CVS/PHARMACY # 01430
2101 S. LAMAR BLVD., UNIT B
AUSTIN, TX 78704
Pharmacy Comments
Contract Details
Approval Date
4/5/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/18/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tony DeDominico, COO
(512) 324-6046
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/5/2021
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