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CVS PHARMACY, INC.
DSH450684 MEMORIAL HERMANN NORTHEAST HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL HERMANN NORTHEAST HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450684
Entity Address
18951 N. Memorial Drive
Humble, TX 77338
Medicare Provider Number
450684
Participating Start Date
9/9/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
DBA CVS/PHARMACY #10979
17900 WEST LAKE HOUSTON PARKWAY
HUMBLE, TX 77346
Pharmacy Comments
Contract Details
Approval Date
10/4/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Randy Reid, VP, Finance
(281) 540-7802
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/4/2019
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