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HEB PHARMACY #064
DSH450101 HILLCREST BAPTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
HILLCREST BAPTIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450101
Entity Address
100 HILLCREST MEDICAL BLVD
WACO, TX 76712
Medicare Provider Number
450101
Participating Start Date
7/1/2005
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #064
Pharmacy Address
3801 N. 19TH STREET
WACO, TX 76708
Pharmacy Comments
Contract Details
Approval Date
4/7/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHARLES E WILLIAMS, PRESIDENT
(254) 202-9414
Contract Pharmacy Representative
HEB
Kimberly Lavrack, Director of Third Party
(210) 938-7344
Signed By Date
4/7/2023
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