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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/28/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Randy Reid, VP, Finance
(281) 540-7802
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/28/2017
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