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HEB PHARMACY #052
SCH450571-00 SHANNON MEDICAL CENTER
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Covered Entity Details
Entity Name
SHANNON MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450571-00
Entity Address
120 EAST HARRIS AVENUE
SAN ANGELO, TX 76903
Medicare Provider Number
450571
Participating Start Date
7/1/2021
Last Recertification Date
8/19/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
HEB PHARMACY #052
Pharmacy Address
3301 SHERWOOD WAY
SAN ANGELO, TX 76901
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
8/9/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Joseph Wooldridge, Chief Financial Officer
(325) 657-5303
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
7/15/2021
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