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HEB PHARMACY #554
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
HEB PHARMACY #554
Pharmacy Address
1505 E. RIO GRANDE
VICTORIA, TX 77901
Pharmacy Comments
Contract Details
Approval Date
1/3/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JASON ANGLIN, CEO
(361) 552-6713 Ext: 240
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
1/3/2019
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