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CORAM HEALTHCARE CORPORATION OF NORTH TE
PED453300-00 COOK CHILDREN'S MEDICAL CENTER
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Covered Entity Details
Entity Name
COOK CHILDREN'S MEDICAL CENTER
Subdivision Name
Type
Children's Hospital
340B ID
PED453300-00
Entity Address
801 SEVENTH AVENUE
FORT WORTH, TX 76104-2733
Medicare Provider Number
453300
Participating Start Date
2/26/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
CORAM HEALTHCARE CORPORATION OF NORTH TE
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
10105 TECHNOLOGY BLVD. WEST
SUITE 102
DALLAS, TX 75220
Pharmacy Comments
Contract Details
Approval Date
4/8/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/28/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Nancy Cychol, EVP, Hospital Services
(682) 885-4340
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/8/2021
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