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MAXOR SPECIALTY PHARMACY
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
MAXOR SPECIALTY PHARMACY
Pharmacy Address
150 CLEVELAND RD
SUITE B
BOGART, GA 30622-1701
Pharmacy Comments
Contract Details
Approval Date
4/19/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nancy Cychol, EVP, Hospital Services
(682) 885-4340
Contract Pharmacy Representative
Maxor National Pharmacy Services
Michael T Einodshofer, Executive Vice President, Maxor Specialty
(724) 243-8822
Signed By Date
4/19/2021
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