Contract Pharmacy Details

WALGREEN CO.
DSH450684 MEMORIAL HERMANN NORTHEAST HOSPITAL

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

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 05671
4445 KINGWOOD DRIVE
KINGWOOD, TX 77339

Pharmacy Comments

Contract Details

Approval Date

12/4/2012

Contract Begin Date

12/4/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/8/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Louis Smith, CEO
(281) 540-7801

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

9/28/2012

340B Drug Pricing Program Database