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CVS PHARMACY, INC.
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
CVS PHARMACY, INC.
Pharmacy Address
DBA CVS/PHARMACY # 10221
2502 TRIMMIER RD.
KILLEEN, TX 76542
Pharmacy Comments
Contract Details
Approval Date
7/7/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/8/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carlyle Walton, CEO
(254) 519-8165
Contract Pharmacy Representative
John Zevzavadjian, Vice President, Payer Relations
(480) 391-4600
Signed By Date
7/7/2014
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