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KROGER PHARMACY #256
DSH450018 UNIVERSITY OF TEXAS MEDICAL BRANCH
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Covered Entity Details
Entity Name
UNIVERSITY OF TEXAS MEDICAL BRANCH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450018
Entity Address
301 UNIVERSITY BLVD
GALVESTON, TX 77555
Medicare Provider Number
450018
Participating Start Date
4/1/1994
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #256
Pharmacy Address
1804 N VELASCO
ANGLETON, TX 77515
Pharmacy Comments
Contract Details
Approval Date
1/18/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Carolee A. King, Senior Vice President & General Counsel
(409) 772-1904
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/18/2022
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