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AVITA PHARMACY 1028
DSH450051 METHODIST DALLAS MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST DALLAS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450051
Entity Address
1441 NORTH BECKLEY AVENUE
DALLAS, TX 75203
Medicare Provider Number
450051
Participating Start Date
7/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
Pharmacy Comments
Contract Details
Approval Date
10/29/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
LAURA L. IRVINE, PRESIDENT
(214) 947-2523
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
10/29/2014
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