Contract Pharmacy Details

KROGER PHARMACY #241
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 #241

Pharmacy Address

3410 GULF FREEWAY
DICKINSON, TX 77539

Pharmacy Comments

Contract Details

Approval Date

3/20/2012

Contract Begin Date

3/20/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/15/2024
Business decision by covered entity and/or pharmacy

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