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SHANNON PHARMACY
DSH450571 SHANNON MEDICAL CENTER
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Covered Entity Details
Entity Name
SHANNON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450571
Entity Address
120 EAST HARRIS AVENUE
SAN ANGELO, TX 76903
Medicare Provider Number
450571
Participating Start Date
7/1/2022
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
SHANNON PHARMACY
Pharmacy Address
122 S OAKES ST STE 100
SAN ANGELO, TX 76903
Pharmacy Comments
Contract Details
Approval Date
6/28/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Contacts
Covered Entity Signing Official
Kelly Shane Plymell, Chief Operating Officer
(325) 657-5303
Contract Pharmacy Representative
BRYAN HORNER, CHIEF EXECUTIVE OFFICER
(325) 655-8191
Signed By Date
6/28/2015
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