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WALGREEN CO.
DSH450610 MEMORIAL HERMANN MEMORIAL CITY MEDIC
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Covered Entity Details
Entity Name
MEMORIAL HERMANN MEMORIAL CITY MEDIC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450610
Entity Address
921 GESSNER RD
HOUSTON, TX 77024
Medicare Provider Number
450610
Participating Start Date
7/1/2023
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #10846
6400 FANNIN ST STE 102
HOUSTON, TX 77030
Pharmacy Comments
Contract Details
Approval Date
7/14/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robert C Ogden, Associate Vice President of Finance
(713) 456-5111
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/14/2023
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