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HEB PHARMACY #403
CAH451379-00 CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
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Covered Entity Details
Entity Name
CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451379-00
Entity Address
1507 W MAIN ST
GATESVILLE, TX 76528-1024
Medicare Provider Number
451379
Participating Start Date
9/29/2010
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #403
Pharmacy Address
1207 MAIN ST
GATESVILLE, TX 76528
Pharmacy Comments
Contract Details
Approval Date
7/17/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID BYROM, CEO
(254) 865-8251 Ext: 6300
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
7/17/2017
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