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CVS PHARMACY, INC.
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
CVS PHARMACY, INC.
Pharmacy Address
DBA CVS/PHARMACY #10544
5902 FM 1463 ROAD
KATY, TX 77494
Pharmacy Comments
Contract Details
Approval Date
10/23/2023
Contract Begin Date
1/1/2024
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
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/23/2023
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