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HEB PHARMACY #734
DSH450571 SHANNON MEDICAL CENTER
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Covered Entity Details
Entity Name
SHANNON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450571
Entity Address
120 EAST HARRIS AVENUE
SAN ANGELO, TX 76903
Medicare Provider Number
450571
Participating Start Date
7/1/2022
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #734
Pharmacy Address
5502 SHERWOOD WAY
SAN ANGELO, TX 76901
Pharmacy Comments
Contract Details
Approval Date
5/6/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2023
Business decision by covered entity and/or pharmacy
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
4/15/2022
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