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HEB PHARMACY #099
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
HEB PHARMACY #099
Pharmacy Address
10919 LOUETTA DR.
HOUSTON, TX 77070
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Makiltru L Fontenette, ACNO
(281) 757-0976
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
1/14/2021
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