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HEB PHARMACY #599
DSH320002 ST. VINCENT HOSPITAL
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Covered Entity Details
Entity Name
ST. VINCENT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320002
Entity Address
455 ST. MICHAELS DRIVE
SANTA FE, NM 87505
Medicare Provider Number
320002
Participating Start Date
1/1/2014
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #599
Pharmacy Address
5225A BUFFALO SPEEDWAY
HOUSTON, TX 77005
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/28/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lillian Montoya, President and CEO
(505) 913-5258
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
4/12/2019
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