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MANIFEST PHARMACY, LLC
DSH450369A CHILDRESS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
CHILDRESS REGIONAL MEDICAL CENTER
Subdivision Name
FOX RURAL HEALTH CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH450369A
Entity Address
1001 US HWY 83 NORTH
CHILDRESS, TX 79201
Medicare Provider Number
450369
Outpatient Facility Provider Number
Participating Start Date
4/1/2016
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
MANIFEST PHARMACY, LLC
Pharmacy Address
1018 S BATESVILLE RD
STE 4A
GREER, SC 29650-5203
Pharmacy Comments
Contract Details
Approval Date
7/1/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOHN HENDERSON, CEO
(940) 937-9178
Contract Pharmacy Representative
Benjamin Walvoord, President
(864) 990-2880
Signed By Date
7/1/2013
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