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WAL-MART PHARMACY 10-0249
DSH450684 MEMORIAL HERMANN NORTHEAST HOSPITAL
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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
WAL-MART PHARMACY 10-0249
Pharmacy Address
831 HWY. 59 SOUTH
CLEVELAND, TX 77327
Pharmacy Comments
Contract Details
Approval Date
10/8/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/26/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rebecca Tucker, VP, Finance
(713) 456-5340
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/8/2014
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