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WALGREEN CO.
DSH450102 CHRISTUS MOTHER FRANCES HOSP-TYLER
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Covered Entity Details
Entity Name
CHRISTUS MOTHER FRANCES HOSP-TYLER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450102
Entity Address
800 EAST DAWSON
TYLER, TX 75701
Medicare Provider Number
450102
Participating Start Date
3/10/2022
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11910
1130 S. BROADWAY ST.
SULPHUR SPRINGS, TX 75482-4840
Pharmacy Comments
Contract Details
Approval Date
10/14/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Elizabeth Pulliam, Chief Financial Officer
(903) 606-4102
Contract Pharmacy Representative
Walgreens
Edwin Raff, DVP Contracting & Pricing
(847) 964-6198
Signed By Date
10/14/2022
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