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KINGSLAND HEALTH MART PHARMACY
SCH450219-00 Baylor Scott & White Medical Center - Llano
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Covered Entity Details
Entity Name
Baylor Scott & White Medical Center - Llano
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450219-00
Entity Address
200 W. Ollie St.
Llano, TX 78643
Medicare Provider Number
450219
Participating Start Date
10/1/2013
Last Recertification Date
9/6/2016
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
KINGSLAND HEALTH MART PHARMACY
Pharmacy Address
3 ROBERT LLC
306 RANCH ROAD 2900
KINGSLAND, TX 78639
Pharmacy Comments
Contract Details
Approval Date
4/9/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Ernie Bovio, CEO
(325) 247-7868
Contract Pharmacy Representative
Corner Drug
Todd Humphries, Owner
(325) 247-4155
Signed By Date
4/9/2014
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