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KROGER PHARMACY #366
DSH450844 HOUSTON METHODIST WILLOWBROOK HOSPITAL
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Covered Entity Details
Entity Name
HOUSTON METHODIST WILLOWBROOK HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450844
Entity Address
18220 STATE HIGHWAY 249
HOUSTON, TX 77070-4347
Medicare Provider Number
450844
Participating Start Date
4/1/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #366
Pharmacy Address
12434 TOMBALL PARKWAY
HOUSTON, TX 77086
Pharmacy Comments
Contract Details
Approval Date
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/6/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Makiltru L Fontenette, ACNO
(281) 757-0976
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/14/2020
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