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HEB PHARMACY #091
PED453310-00 Ascension Seton d/b/a Dell Children's Medical Center of Central Texas
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Covered Entity Details
Entity Name
Ascension Seton d/b/a Dell Children's Medical Center of Central Texas
Subdivision Name
Type
Children's Hospital
340B ID
PED453310-00
Entity Address
4900 MUELLER BOULEVARD
AUSTIN, TX 78723
Medicare Provider Number
453310
Participating Start Date
7/1/2010
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #091
Pharmacy Address
2508 E RIVERSIDE DRIVE
AUSTIN, TX 78741
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/18/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Debra Marie Brown, VP, Patient Care Services and COO
(512) 324-0186
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
7/17/2018
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