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MEDICAL PLAZA PHARMACY
DSH450037 GOOD SHEPHERD MEDICAL CENTER
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Covered Entity Details
Entity Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450037
Entity Address
700 E. MARSHALL AVENUE
LONGVIEW, TX 75601
Medicare Provider Number
450037
Participating Start Date
7/1/2010
Last Recertification Date
8/29/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
MEDICAL PLAZA PHARMACY
Pharmacy Address
615 N 3RD ST STE 1
LONGVIEW, TX 75601
Pharmacy Comments
Contract Details
Approval Date
10/14/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
PAT KEEL, EXECUTIVE VICE PRESIDENT/CFO
(903) 315-1820
Contract Pharmacy Representative
Don Novak, Owner
(903) 757-3477
Signed By Date
10/14/2013
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