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SUPER D DRUGS ACQUISITION CO.
DSH450801 CHRISTUS ST MICHAEL
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Covered Entity Details
Entity Name
CHRISTUS ST MICHAEL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450801
Entity Address
2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503
Medicare Provider Number
450801
Participating Start Date
4/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
SUPER D DRUGS ACQUISITION CO.
Pharmacy Address
DBA: WALGREENS #15790
191 WEST MAIN
ASHDOWN, AR 71822
Pharmacy Comments
Contract Details
Approval Date
10/20/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Christopher Karam, President & CEO
(903) 614-2001
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/20/2015
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