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HEB PHARMACY WAREHOUSE 208
DSH320002 ST. VINCENT HOSPITAL
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Covered Entity Details
Entity Name
ST. VINCENT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320002
Entity Address
455 ST. MICHAELS DRIVE
SANTA FE, NM 87505
Medicare Provider Number
320002
Participating Start Date
1/1/2014
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY WAREHOUSE 208
Pharmacy Address
H-E-B, LP
5311 DIETRICH RD STE 100
SAN ANTONIO, TX 78219
Pharmacy Comments
Contract Details
Approval Date
7/14/2023
Contract Begin Date
7/14/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lillian Montoya, President and CEO
(505) 913-5258
Contract Pharmacy Representative
HEB
Kimberly Lavrack, Director of Third Party
(210) 938-7344
Signed By Date
7/14/2023
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