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BAYLOR SCOTT & WHITE PHARMACY #113
DSH450021 BAYLOR UNIVERSITY MEDICAL CTR
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Covered Entity Details
Entity Name
BAYLOR UNIVERSITY MEDICAL CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450021
Entity Address
3500 GASTON AVENUE
DALLAS, TX 75246
Medicare Provider Number
450021
Participating Start Date
3/7/2023
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
BAYLOR SCOTT & WHITE PHARMACY #113
Pharmacy Address
BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,
3800 GAYLORD PKWY STE 110
FRISCO, TX 75034
Pharmacy Comments
Contract Details
Approval Date
3/6/2023
Contract Begin Date
3/7/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kyle Armstrong, President
(214) 820-3101
Contract Pharmacy Representative
Baylor Health Enterprises
Eric Gaines, Dir Outpatient Pharmacy
(469) 814-5798
Signed By Date
1/9/2023
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