Contract Pharmacy Details

CVS PHARMACY, INC.
CAH451380-00 East Texas Medical Center Quitman

Covered Entity Details

Entity Name

East Texas Medical Center Quitman

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH451380-00

Entity Address

117 N. Winnsboro Street
Quitman, TX 75783

Medicare Provider Number

451380

Participating Start Date

4/1/2013

Last Recertification Date

11/7/2017

Entity Termination Date

4/1/2018

Pharmacy Details

Pharmacy Name

CVS PHARMACY, INC.

Pharmacy Address

DBA CVS/PHARMACY #10340
210 EAST BROAD STREET
MINEOLA, TX 75773

Pharmacy Comments

Contract Details

Approval Date

4/6/2016

Contract Begin Date

7/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Warren J. Robicheaux, Sr. Administrator
(903) 946-5501

Contract Pharmacy Representative

CVS Health
Jaclyn Parfitt, 340B Operations Manager
(401) 770-6467

Signed By Date

4/6/2016

340B Drug Pricing Program Database