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BROOKSHIRE PHARMACY #03
RRC450102-00 CHRISTUS MOTHER FRANCES HOSP-TYLER
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Covered Entity Details
Entity Name
CHRISTUS MOTHER FRANCES HOSP-TYLER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC450102-00
Entity Address
800 EAST DAWSON ST.
TYLER, TX 75701
Medicare Provider Number
450102
Participating Start Date
8/13/2020
Last Recertification Date
8/20/2021
Entity Termination Date
3/10/2022
Pharmacy Details
Pharmacy Name
BROOKSHIRE PHARMACY #03
Pharmacy Address
521 SOUTH MAIN
PO BOX 880
LINDALE, TX 75771
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/10/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Elizabeth Pulliam, Chief Financial Officer
(903) 606-4102
Contract Pharmacy Representative
Brookshire Grocery Company
Neil Ducote, Director of Pharmacy
(903) 600-1376
Signed By Date
1/13/2022
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