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PRESCRIPTION SHOP
DSH450755B Methodist Hospital Levelland (DBA Covenant Hospital Levelland)
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Covered Entity Details
Entity Name
Methodist Hospital Levelland (DBA Covenant Hospital Levelland)
Subdivision Name
FAMILY MEDICINE CLINIC RHC
Type
Disproportionate Share Hospital
340B ID
DSH450755B
Entity Address
116 A JOHN DUPREE DR.
LEVELLAND, TX 79336
Medicare Provider Number
450755
Outpatient Facility Provider Number
458605
Participating Start Date
7/1/2011
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
PRESCRIPTION SHOP
Pharmacy Address
LITTLEFIELD PRESCRIPTION SHOP, LLC
1506 S SUNSET AVE STE A
LITTLEFIELD, TX 79339-7933
Pharmacy Comments
04/16/2012 updated name (was Prescription Shop)
Contract Details
Approval Date
4/14/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/12/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Newman D. Wheeler, COO/CFO
(806) 568-1304
Contract Pharmacy Representative
MICAH PRATT, RPH
(806) 385-4491
Signed By Date
4/14/2017
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