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WALGREEN CO.
PED453310-00 Ascension Seton d/b/a Dell Children's Medical Center of Central Texas
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Covered Entity Details
Entity Name
Ascension Seton d/b/a Dell Children's Medical Center of Central Texas
Subdivision Name
Type
Children's Hospital
340B ID
PED453310-00
Entity Address
4900 MUELLER BOULEVARD
AUSTIN, TX 78723
Medicare Provider Number
453310
Participating Start Date
7/1/2010
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09143
504 STATE HIGHWAY 71 WEST
BASTROP, TX 78602
Pharmacy Comments
Contract Details
Approval Date
10/22/2012
Contract Begin Date
10/22/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BOB BONAR, CEO
(512) 324-0106
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/4/2012
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