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HEB PHARMACY #543
CAH451322-00 Grimes St. Joseph Health Center
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Covered Entity Details
Entity Name
Grimes St. Joseph Health Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451322-00
Entity Address
210 S. Judson St
Navasota, TX 77868
Medicare Provider Number
451322
Participating Start Date
1/1/2013
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #543
Pharmacy Address
1900 TEXAS AVENUE SOUTH
COLLEGE STATION, TX 77840
Pharmacy Comments
Contract Details
Approval Date
7/26/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/25/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ricardo Diaz, Chief Operating Officer
(979) 776-2580
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
7/26/2013
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