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BAYLOR SCOTT & WHITE PHARMACY #103
DSH450021 BAYLOR UNIVERSITY MEDICAL CTR
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Covered Entity Details
Entity Name
BAYLOR UNIVERSITY MEDICAL CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450021
Entity Address
3500 GASTON AVENUE
DALLAS, TX 75246
Medicare Provider Number
450021
Participating Start Date
3/7/2023
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
BAYLOR SCOTT & WHITE PHARMACY #103
Pharmacy Address
BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,
3410 WORTH ST STE 240
DALLAS, TX 75246
Pharmacy Comments
Contract Details
Approval Date
4/20/2011
Contract Begin Date
5/1/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
4/13/2011
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