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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05833
1801 FM 1765
LA MARQUE, TX 77568
Pharmacy Comments
05/03/2012 updated address (was 1801 FM 1765 Road)
Contract Details
Approval Date
4/15/2014
Contract Begin Date
7/1/2014
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/15/2014
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