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SOUTHSIDE PHARMACY II
PED453304-00 Texas Children's Hospital
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Covered Entity Details
Entity Name
Texas Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED453304-00
Entity Address
6621 Fannin Street
Houston, TX 77030-2303
Medicare Provider Number
453304
Participating Start Date
1/1/2012
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
SOUTHSIDE PHARMACY II
Pharmacy Address
1331 W GRAND PKWY N
STE 111
KATY, TX 77493-2711
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/24/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Weldon Gage, Executive Vice President/CFO
(832) 826-8084
Contract Pharmacy Representative
ACCT
Nandan Kumar, Director of Pharmacy Operations
(713) 660-8888 Ext: 1220
Signed By Date
1/17/2017
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