Contract Pharmacy Details

KROGER PHARMACY #108
DSH450018 UNIVERSITY OF TEXAS MEDICAL BRANCH

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 #108

Pharmacy Address

3541 PALMER @ HWY 146
TEXAS CITY, TX 77590

Pharmacy Comments

05/04/2012 updated address (was 3541 Palmer Hwy)

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

340B Drug Pricing Program Database