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MEDICAL PLAZA PHARMACY
RRC450032-00 GOOD SHEPHERD MEDICAL CENTER
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Covered Entity Details
Entity Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC450032-00
Entity Address
811 SOUTH WASHINGTON
MARSHALL, TX 75670
Medicare Provider Number
450032
Participating Start Date
11/30/2020
Last Recertification Date
8/18/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
MEDICAL PLAZA PHARMACY
Pharmacy Address
615 N 3RD ST STE 1
LONGVIEW, TX 75601
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael Cheek, CFO
(903) 315-1814
Contract Pharmacy Representative
Medical Plaza Pharmacy
Don Novak, Pharmacist/Owner
(903) 234-8329
Signed By Date
4/14/2022
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