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MEDICINE MAN PHARMACY - PORT LAVACA
CAH451356-00 MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MEMORIAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451356-00
Entity Address
815 N VIRGINIA STREET
PORT LAVACA, TX 77979
Medicare Provider Number
451356
Participating Start Date
9/16/2010
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
MEDICINE MAN PHARMACY - PORT LAVACA
Pharmacy Address
1202 NORTH VIRGINIA STREET
PORT LAVACA, TX 77979
Pharmacy Comments
Contract Details
Approval Date
10/12/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/5/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
JASON ANGLIN, CEO
(361) 552-6713 Ext: 240
Contract Pharmacy Representative
Medicine Man Pharmacy
John Rogers, COO
(361) 482-0345
Signed By Date
10/12/2017
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