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MEMORIAL HERMANN PHARMACY
DSH450684 MEMORIAL HERMANN NORTHEAST HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL HERMANN NORTHEAST HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450684
Entity Address
18951 N. Memorial Drive
Humble, TX 77338
Medicare Provider Number
450684
Participating Start Date
9/9/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
MEMORIAL HERMANN PHARMACY
Pharmacy Address
27700 NW FWY, STE 150
CYPRESS, TX 77433
Pharmacy Comments
Contract Details
Approval Date
1/17/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Randy Reid, VP, Finance
(281) 540-7802
Contract Pharmacy Representative
Memorial Hermann
Bonnie Richardson, Pharmacy Manager
(346) 231-6971
Signed By Date
1/17/2018
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