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BAYLOR SCOTT & WHITE PHARMACY #254
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
BAYLOR SCOTT & WHITE PHARMACY #254
Pharmacy Address
BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,
50 HILLCREST MEDICAL BLVD STE 200-1
WACO, TX 76712
Pharmacy Comments
Contract Details
Approval Date
7/5/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shahin Motakef, CEO
(254) 724-6583
Contract Pharmacy Representative
Baylor Scott & White Health
Ping Du, VP Pharmacy Outpatient
(469) 764-1133
Signed By Date
7/5/2017
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