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HEB PHARMACY #182
DSH450152 AdventHealth Central Texas
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Covered Entity Details
Entity Name
AdventHealth Central Texas
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450152
Entity Address
2201 S. CLEAR CREEK ROAD
KILLEEN, TX 76549
Medicare Provider Number
450152
Participating Start Date
4/1/2010
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #182
Pharmacy Address
3002 S. 31ST STREET
TEMPLE, TX 76502
Pharmacy Comments
Contract Details
Approval Date
10/17/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/8/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carlyle Walton, CEO
(254) 519-8165
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
10/17/2013
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