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HEB SPECIALTY PHARMACY #701
DSH450844 HOUSTON METHODIST WILLOWBROOK HOSPITAL
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Covered Entity Details
Entity Name
HOUSTON METHODIST WILLOWBROOK HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450844
Entity Address
18220 STATE HIGHWAY 249
HOUSTON, TX 77070-4347
Medicare Provider Number
450844
Participating Start Date
4/1/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
HEB SPECIALTY PHARMACY #701
Pharmacy Address
3503 FREDERICKSBURG RD
STE 450
SAN ANTONIO, TX 78201
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nicole Twine, Vice President / CNO
(281) 387-6505
Contract Pharmacy Representative
HEB
Kimberly Lavrack, Director of Third Party
(210) 938-7344
Signed By Date
1/17/2023
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