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SHANNON SPECIALTY PHARMACY
DSH450571 SHANNON MEDICAL CENTER
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Covered Entity Details
Entity Name
SHANNON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450571
Entity Address
120 EAST HARRIS AVENUE
SAN ANGELO, TX 76903
Medicare Provider Number
450571
Participating Start Date
7/1/2022
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
SHANNON SPECIALTY PHARMACY
Pharmacy Address
2030 PULLIAM ST.
STE. 16
SAN ANGELO, TX 76905
Pharmacy Comments
Contract Details
Approval Date
7/12/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2024
Ownership change
Contacts
Covered Entity Signing Official
Joseph Wooldridge, Chief Financial Officer
(325) 657-5303
Contract Pharmacy Representative
Shannon Pharmacy
Carlos Robledo, PIC
(325) 655-8191
Signed By Date
7/12/2024
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