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GLENWOOD PHARMACY
RRC450801-00 CHRISTUS ST MICHAEL
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Covered Entity Details
Entity Name
CHRISTUS ST MICHAEL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC450801-00
Entity Address
2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503
Medicare Provider Number
450801
Participating Start Date
1/1/2025
Last Recertification Date
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
GLENWOOD PHARMACY
Pharmacy Address
1400 COLLEGE DRIVE
TEXARKANA, TX 75503
Pharmacy Comments
Contract Details
Approval Date
10/23/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jason Adams, President
(903) 614-2001
Contract Pharmacy Representative
Glenwood Pharmacy
Daniel Lukas, Head Pharmacist
(903) 792-8296
Signed By Date
10/7/2024
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