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TEXAS HEALTH RESOURCES INFUSION PHARMACY
DSH450135 TEXAS HEALTH HARRIS METHODIST FORT WORTH
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Covered Entity Details
Entity Name
TEXAS HEALTH HARRIS METHODIST FORT WORTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450135
Entity Address
1301 PENNSYLVANIA AVENUE
FORT WORTH, TX 76104
Medicare Provider Number
450135
Participating Start Date
1/1/2016
Last Recertification Date
8/29/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
TEXAS HEALTH RESOURCES INFUSION PHARMACY
Pharmacy Address
1100 BRIDGEWOOD DR, STE 107
FORT WORTH, TX 76112
Pharmacy Comments
Contract Details
Approval Date
10/11/2017
Contract Begin Date
10/19/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Shelly Miland, VP Finance
(817) 250-3478
Contract Pharmacy Representative
Texas Health
Ted Menard, Director Pharmacy
(682) 236-2423
Signed By Date
10/11/2017
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