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BEST VALUE WADDY PHARMACY
DSH450565 Palo Pinto General Hospital
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Covered Entity Details
Entity Name
Palo Pinto General Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450565
Entity Address
400 SW 25th Avenue
Mineral Wells, TX 76067-8246
Medicare Provider Number
450565
Participating Start Date
10/1/2011
Last Recertification Date
9/13/2024
Pharmacy Details
Pharmacy Name
BEST VALUE WADDY PHARMACY
Pharmacy Address
106 SW 6TH AVE
MINERAL WELLS, TX 76067
Pharmacy Comments
Contract Details
Approval Date
11/18/2011
Contract Begin Date
11/25/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/6/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ken Roark, Director of Pharmacy
(940) 328-6325
Contract Pharmacy Representative
Robert Waddy, Pharmacist in Charge
(940) 328-1991
Signed By Date
11/30/2011
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