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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
COMMUNITY, A WALGREENS PHARMACY #21375
3910 GASTON AVE STE 125
DALLAS, TX 75246
Pharmacy Comments
Contract Details
Approval Date
10/3/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/9/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/3/2016
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