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PROCARE PHARMACY, L.L.C.
PED453306-00 Methodist Children's Hospital d/b/a Covenant Children's Hospital
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Covered Entity Details
Entity Name
Methodist Children's Hospital d/b/a Covenant Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED453306-00
Entity Address
4015 22nd Place
Lubbock, TX 79410
Medicare Provider Number
453306
Participating Start Date
1/1/2018
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
4/13/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Grigson, CFO
(806) 725-0598
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/13/2021
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