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CVS PHARMACY, INC.
PED453302-00 CHILDREN'S MEDICAL CENTER DALLAS
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Covered Entity Details
Entity Name
CHILDREN'S MEDICAL CENTER DALLAS
Subdivision Name
Type
Children's Hospital
340B ID
PED453302-00
Entity Address
1935 MEDICAL DISTRICT DRIVE
DALLAS, TX 75235
Medicare Provider Number
453302
Participating Start Date
4/1/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
DBA: CVS/PHARMACY # 07412
5370 W LOVERS LN STE 310
DALLAS, TX 75209
Pharmacy Comments
Contract Details
Approval Date
10/22/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHRISTOPHER J. DUROVICH, PRESIDENT & CEO
(214) 456-7890
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
10/22/2013
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