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CVS PHARMACY, INC.
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
CVS PHARMACY, INC.
Pharmacy Address
DBA: CVS/PHARMACY # 07821
5002 W MAIN ST
LEAGUE CITY, TX 77573
Pharmacy Comments
Contract Details
Approval Date
10/16/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David M. Connaughton, Vice President, Finance – Clinical Enterprise
(409) 772-3446
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
10/16/2013
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