Contract Pharmacy Details

ALBERTSONS LLC
DSH450051 METHODIST DALLAS MEDICAL CENTER

Covered Entity Details

Entity Name

METHODIST DALLAS MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH450051

Entity Address

1441 NORTH BECKLEY AVENUE
DALLAS, TX 75203

Medicare Provider Number

450051

Participating Start Date

7/1/2005

Last Recertification Date

9/6/2024

Pharmacy Details

Pharmacy Name

ALBERTSONS LLC

Pharmacy Address

ALBERTSONS PHARMACY # 4260
2165 E BUCKINGHAM RD
RICHARDSON, TX 75081

Pharmacy Comments

Contract Details

Approval Date

1/15/2018

Contract Begin Date

4/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/28/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Martin L. Koonsman, President
(214) 947-2523

Contract Pharmacy Representative

Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304

Signed By Date

1/15/2018

340B Drug Pricing Program Database