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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05435
3100 MILLER AVE.
FT WORTH, TX 76105
Pharmacy Comments
Contract Details
Approval Date
10/15/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/18/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Nancy Cychol, EVP, Hospital Services
(682) 885-4340
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2015
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