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WAL-MART PHARMACY 10-3298
DSH450184 MEMORIAL HERMANN HOSPITAL SYSTEM
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Covered Entity Details
Entity Name
MEMORIAL HERMANN HOSPITAL SYSTEM
Subdivision Name
Memorial Hermann Southwest Hospital
Type
Disproportionate Share Hospital
340B ID
DSH450184
Entity Address
7600 Beechnut
Houston, TX 77074
Medicare Provider Number
450184
Participating Start Date
2/7/2018
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3298
Pharmacy Address
255 FM 518
KEMAH, TX 77565
Pharmacy Comments
Contract Details
Approval Date
10/20/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DAVID STRICKLER, CHIEF FINANCIAL OFFICER
(713) 456-5340
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/20/2014
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