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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15318
3826 CEDAR SPRINGS RD
DALLAS, TX 75219
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/24/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Martin L. Koonsman, President
(214) 947-2523
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/15/2016
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