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WAL-MART PHARMACY 10-3500
DSH450068 Memorial Hermann Texas Medical Center
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Covered Entity Details
Entity Name
Memorial Hermann Texas Medical Center
Subdivision Name
Memorial Hermann Texas Medical Center
Type
Disproportionate Share Hospital
340B ID
DSH450068
Entity Address
6411 Fannin St.
Houston, TX 77030
Medicare Provider Number
450068
Participating Start Date
4/1/1994
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3500
Pharmacy Address
5655 EAST SAM HOUSTON PKWY N
HOUSTON, TX 77015
Pharmacy Comments
Contract Details
Approval Date
10/10/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/26/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brian Dean, CFO
(713) 704-5292
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/10/2014
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