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MARKET STREET PHARMACY #553
DSH450686 UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450686
Entity Address
602 INDIANA AVE
LUBBOCK, TX 79415
Medicare Provider Number
450686
Participating Start Date
12/1/1992
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
MARKET STREET PHARMACY #553
Pharmacy Address
4425 19TH STREET
LUBBOCK, TX 79407
Pharmacy Comments
Contract Details
Approval Date
10/14/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/26/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DAVID ALLISON, CEO
(806) 775-8517
Contract Pharmacy Representative
Tim Purser, Director of Pharmacy
(806) 791-7410
Signed By Date
10/14/2014
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