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KROGER PHARMACY #356
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
KROGER PHARMACY #356
Pharmacy Address
1352 W 43RD STREET
HOUSTON, TX 77018
Pharmacy Comments
Contract Details
Approval Date
4/15/2015
Contract Begin Date
7/1/2015
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
Memorial Hermann System
Jo Ann Maack, System Pharmacy Director
(713) 242-2814
Signed By Date
4/15/2015
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