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RECEPT PHARMACY #5
DSH450068 Memorial Hermann Texas Medical Center
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Covered Entity Details
Entity Name
Memorial Hermann Texas Medical Center
Subdivision Name
Memorial Hermann Texas Medical Center
Type
Disproportionate Share Hospital
340B ID
DSH450068
Entity Address
6411 Fannin St.
Houston, TX 77030
Medicare Provider Number
450068
Participating Start Date
4/1/1994
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
RECEPT PHARMACY #5
Pharmacy Address
1469 WEST STATE HIGHWAY 114
SUITE 598
GRAPEVINE, TX 76051
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/26/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bryan Lee, VP, Finance
(713) 704-4710
Contract Pharmacy Representative
Recept
Vaughn Kinosian, Vice President of Operations
(401) 952-8627
Signed By Date
10/15/2018
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