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Central Admixture Pharmacy Services, Inc.
DSH450018BS UNIVERSITY OF TEXAS MEDICAL BRANCH
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Covered Entity Details
Entity Name
UNIVERSITY OF TEXAS MEDICAL BRANCH
Subdivision Name
UTMB LCC Infusion Center
Type
Disproportionate Share Hospital
340B ID
DSH450018BS
Entity Address
2240 GULF FREEWAY SOUTH
LEAGUE CITY, TX 77573
Medicare Provider Number
450018
Outpatient Facility Provider Number
Participating Start Date
7/1/2011
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
Central Admixture Pharmacy Services, Inc.
Pharmacy Address
1000 S. Loop West, Ste 115
Houston, TX 77054
Pharmacy Comments
07/26/2013: Pharmacy address corrected, changed in error on 3/28/2013, see history for details.
Contract Details
Approval Date
6/8/2012
Contract Begin Date
6/8/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David M. Connaughton, Vice President, Finance – Clinical Enterprise
(409) 772-3446
Contract Pharmacy Representative
Mike Koch, Vice President
(949) 660-2701
Signed By Date
5/21/2012
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