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KROGER PHARMACY #302
DSH450018 UNIVERSITY OF TEXAS MEDICAL BRANCH
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Covered Entity Details
Entity Name
UNIVERSITY OF TEXAS MEDICAL BRANCH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450018
Entity Address
301 UNIVERSITY BLVD
GALVESTON, TX 77555
Medicare Provider Number
450018
Participating Start Date
4/1/1994
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #302
Pharmacy Address
5730 SEAWALL BLVD.
GALVESTON, TX 77551
Pharmacy Comments
Contract Details
Approval Date
3/20/2012
Contract Begin Date
3/20/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
William R. Elger, EVP and Chief Business and Finance Officer
(409) 266-2006
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
3/1/2012
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