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MEMORIAL HERMANN PHARMACY
DSH450184 MEMORIAL HERMANN HOSPITAL SYSTEM
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Covered Entity Details
Entity Name
MEMORIAL HERMANN HOSPITAL SYSTEM
Subdivision Name
Memorial Hermann Southwest Hospital
Type
Disproportionate Share Hospital
340B ID
DSH450184
Entity Address
7600 Beechnut
Houston, TX 77074
Medicare Provider Number
450184
Participating Start Date
2/7/2018
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
MEMORIAL HERMANN PHARMACY
Pharmacy Address
27700 NW FWY, STE 150
CYPRESS, TX 77433
Pharmacy Comments
Contract Details
Approval Date
1/18/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/28/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Rebecca Tucker, VP, Finance
(713) 456-5340
Contract Pharmacy Representative
Memorial Hermann
Bonnie Richardson, Pharmacy Manager
(346) 231-6971
Signed By Date
1/18/2018
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