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Effective Date: 
1/2020

Documents

 

Instructions

Updated: 1/2020

 

Purpose

Pharmacy providers already enrolled with Texas Medicaid utilize this form to notify HHSC of change in ownership.

 

Detailed Instructions

The form must be submitted in conjunction with the VDP Pharmacy Enrollment Application (Form 1340) when an enrolled pharmacy changes ownership. The completed form must contain both the seller’s and buyer’s notarized signatures.

 

Transmittal

Mail:

Vendor Drug Program (Mail Code 2250)
Texas Health and Human Services Commission
4900 North Lamar Blvd.
Austin, TX 78751

Email:  

vdp-enrollment@hhsc.state.tx.us

 

Questions

Questions about this form should be directed to the Vendor Drug Program by email.