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STOCKTON PHARMACY
SCH450178-00 Pecos County Memorial Hospital
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Covered Entity Details
Entity Name
Pecos County Memorial Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450178-00
Entity Address
387 West IH-10
Fort Stockton, TX 79735
Medicare Provider Number
450178
Participating Start Date
7/1/2013
Last Recertification Date
8/30/2018
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
STOCKTON PHARMACY
Pharmacy Address
616 W DICKINSON BLVD
FORT STOCKTON, TX 79735
Pharmacy Comments
Contract Details
Approval Date
1/8/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Leticia Fox, CFO
(432) 336-4202
Contract Pharmacy Representative
Stockton Pharmacy
Shashwatkumar Patel, PIC
(832) 512-0974
Signed By Date
1/8/2014
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