Contract Pharmacy Details

CVS PHARMACY, INC.
DSH450037 GOOD SHEPHERD MEDICAL CENTER

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

CVS PHARMACY, INC.

Pharmacy Address

DBA: CVS/PHARMACY # 06851
119 W MARSHALL AVE
LONGVIEW, TX 75601

Pharmacy Comments

Contract Details

Approval Date

1/15/2016

Contract Begin Date

4/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

RON SHORT, EXECUTIVE VICE PRESIDENT/CAO
(903) 315-1121

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

1/15/2016

340B Drug Pricing Program Database