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HEB PHARMACY #741
PED453304-00 Texas Children's Hospital
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Covered Entity Details
Entity Name
Texas Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED453304-00
Entity Address
6621 Fannin Street
Houston, TX 77030-2303
Medicare Provider Number
453304
Participating Start Date
1/1/2012
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #741
Pharmacy Address
13401 I-10 EAST
BAYTOWN, TX 77523
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Weldon Gage, Executive Vice President/CFO
(832) 826-8084
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
10/15/2019
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