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MEDICAL PLAZA PHARMACY
DSH450032 GOOD SHEPHERD MEDICAL CENTER
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Covered Entity Details
Entity Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450032
Entity Address
700 E. MARSHALL AVENUE
LONGVIEW, TX 75601
Medicare Provider Number
450032
Participating Start Date
7/1/2022
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
MEDICAL PLAZA PHARMACY
Pharmacy Address
615 N 3RD ST STE 1
LONGVIEW, TX 75601
Pharmacy Comments
Contract Details
Approval Date
5/12/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
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
5/4/2022
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