340B Drug Pricing Program Database
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CVS PHARMACY, INC.
DSH450723 METHODIST CHARLTON MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST CHARLTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450723
Entity Address
3500 WEST WHEATLAND ROAD
DALLAS, TX 75237-3460
Medicare Provider Number
450723
Participating Start Date
7/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
CVSPHARMACY # 17318
5270 S STATE HWY 360
GRAND PRAIRIE, TX 75052
Pharmacy Comments
Contract Details
Approval Date
10/6/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jon T Albrecht, Corporate VP, Chief Pharmacy Officer
(214) 947-2504
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/6/2021
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