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PROCARE PHARMACY, L.L.C.
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
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2751
426 S. HENDERSON STREET
FORT WORTH, TX 76104
Pharmacy Comments
Contract Details
Approval Date
10/13/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joseph Wooldridge, Chief Financial Officer
(325) 657-5303
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/13/2022
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