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KROGER PHARMACY #740
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
KROGER PHARMACY #740
Pharmacy Address
7747 KIRBY DRIVE
HOUSTON, TX 77030
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2024
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
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/15/2021
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