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COVENANT HOSPITAL LEVELLAND
DSH450755D 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
SUNDOWN RHC
Type
Disproportionate Share Hospital
340B ID
DSH450755D
Entity Address
209E. RICHARDSON
SUNDOWN, TX 79372
Medicare Provider Number
450755
Outpatient Facility Provider Number
458822
Participating Start Date
7/1/2011
Last Recertification Date
8/12/2015
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
COVENANT HOSPITAL LEVELLAND
Pharmacy Address
1900 COLLEGE AVE
LEVELLAND, TX 79336-6508
Pharmacy Comments
Contract Details
Approval Date
4/12/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Contacts
Covered Entity Signing Official
John Dolan, CFO
(806) 568-1304
Contract Pharmacy Representative
40755
MARTY COTTENOIR, RPH
(806) 894-4963 Ext: 1314
Signed By Date
4/12/2013
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