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CVS PHARMACY, INC.
DSH450221 MOORE COUNTY HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MOORE COUNTY HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450221
Entity Address
224 EAST 2ND STREET
DUMAS, TX 79029
Medicare Provider Number
450221
Participating Start Date
7/1/2009
Last Recertification Date
11/29/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
DBA CVS/PHARMACY #4820
100 NORTH DUMAS AVENUE
DUMAS, TX 79029
Pharmacy Comments
Contract Details
Approval Date
1/4/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JEFF Ray TURNER, CEO
(806) 935-7171
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/4/2016
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