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COMMUNITY PHARMACY
DSH450034 CHRISTUS HOSPITAL
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Covered Entity Details
Entity Name
CHRISTUS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450034
Entity Address
2830 CALDER STREET
BEAUMONT, TX 77702-1048
Medicare Provider Number
450034
Participating Start Date
5/25/2021
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
COMMUNITY PHARMACY
Pharmacy Address
365 FORSYTHE STREET
BEAUMONT, TX 77701-3304
Pharmacy Comments
Contract Details
Approval Date
4/7/2021
Contract Begin Date
5/28/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/24/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Trevino, CEO, CHRISTUS Health Southeast Texas
(409) 899-7102
Contract Pharmacy Representative
Community Pharmacy
Raj Vora, Pharmacy Manager
(409) 832-6539
Signed By Date
4/6/2021
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