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COOK CHILDREN'S HOME HEALTH
PED453300-00 COOK CHILDREN'S MEDICAL CENTER
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Covered Entity Details
Entity Name
COOK CHILDREN'S MEDICAL CENTER
Subdivision Name
Type
Children's Hospital
340B ID
PED453300-00
Entity Address
801 SEVENTH AVENUE
FORT WORTH, TX 76104-2733
Medicare Provider Number
453300
Participating Start Date
2/26/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
COOK CHILDREN'S HOME HEALTH
Pharmacy Address
1101 W VICKERY BLVD
FORT WORTH, TX 76104-1025
Pharmacy Comments
Contract Details
Approval Date
3/5/2010
Contract Begin Date
3/5/2010
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
RICHARD GOODE, CFO
(682) 885-7127
Contract Pharmacy Representative
MICHAEL R. SIMMONS, PRESIDENT
(682) 885-2400
Signed By Date
2/26/2010
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