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CVS PHARMACY, INC.
CAH451356-00 MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MEMORIAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451356-00
Entity Address
815 N VIRGINIA STREET
PORT LAVACA, TX 77979
Medicare Provider Number
451356
Participating Start Date
9/16/2010
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
225 HARPERS LANDING BLVD
CONROE, TX 77385
Pharmacy Comments
Contract Details
Approval Date
10/8/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/2/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JASON ANGLIN, CEO
(361) 552-6713 Ext: 240
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
10/8/2014
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