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WALGREEN CO.
DSH450054 SCOTT AND WHITE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SCOTT AND WHITE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450054
Entity Address
2401 S 31ST ST
TEMPLE, TX 76508
Medicare Provider Number
450054
Participating Start Date
4/1/2006
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07674
905 CRYSTAL FALLS PKWY
LEANDER, TX 78641
Pharmacy Comments
Contract Details
Approval Date
10/1/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shahin Motakef, CEO
(254) 724-6583
Contract Pharmacy Representative
Sara Rainey, Pharmacy Specialist
(254) 724-2081
Signed By Date
10/1/2015
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