Covered Entity Details

PED453300-59 COOK CHILDREN'S MEDICAL CENTER (Active) - information as of 4/23/2025 10:53:35 PM

Main Details

Name

COOK CHILDREN'S MEDICAL CENTER

Subdivision Name

Dodson Specialty Clinic ~ Prader-Willi Center

Type

Children's Hospital

Rural

340B ID

PED453300-59

Medicare Provider Number

453300

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/1/2024

Participating Start Date

7/1/2024

Participating Approval Date

4/2/2024

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Cook Children's Medical Center
Nancy Cychol, EVP, Hospital Services
(682) 885-4340

Primary Contact

Cook Childrens Medical Center
Haydee Melanie Madrigal, Manager, 340B Program
(682) 303-1606

Addresses

Street Address

1500 Cooper St
Fort Worth, TX 76104

Billing Address

Cook Children's Medical Center
801 7th Avenue
Fort Worth, TX 76104

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
TX	021184901	1891765178,1750369203
OK	100702730A	1891765178,1750369203

Shipping Addresses

Shipping Address 1

Cook Children's Medical Center
801 7th Avenue
Fort Worth, TX 76104

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED453300-01	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Grapevine ~ Hematology & Oncology	1600 W Northwest Highway, Ste 500	Grapevine	TX	Terminated
PED453300-03	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Apheresis	1500 Cooper St	Fort Worth	TX	Active
PED453300-04	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Stem Cell	1500 Cooper St	Fort Worth	TX	Active
PED453300-05	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Radiology and Imaging Center	1500 Cooper St	Fort Worth	TX	Terminated
PED453300-06	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Cardiology Heart Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-07	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Craniofacial	1500 Cooper St	Fort Worth	TX	Active
PED453300-08	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Endocrinology	1500 Cooper St	Fort Worth	TX	Active
PED453300-09	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Gastroenterology & Nutrition	1500 Cooper St	Fort Worth	TX	Active
PED453300-10	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Hematology & Oncology	1500 Cooper St	Fort Worth	TX	Active
PED453300-11	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Infectious Disease	1500 Cooper St	Fort Worth	TX	Active
PED453300-12	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Nephrology	1500 Cooper St	Fort Worth	TX	Active
PED453300-13	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Dialysis	1500 Cooper St	Fort Worth	TX	Active
PED453300-14	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neuropsychology	1500 Cooper St	Fort Worth	TX	Active
PED453300-15	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neurosciences	1500 Cooper St	Fort Worth	TX	Active
PED453300-16	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Pain Management	1500 Cooper St	Fort Worth	TX	Active
PED453300-17	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Pediatric Surgery	1500 Cooper St	Fort Worth	TX	Active
PED453300-18	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Behavioral Health Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-19	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Southlake ~ Behavioral Health Clinic	2727 E Southlake Blvd	Southlake	TX	Active
PED453300-20	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Pulmonary Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-21	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Rheumatology	1500 Cooper St	Fort Worth	TX	Active
PED453300-22	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Ambulatory Surgery Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-23	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Infusion Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-24	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Hemophilia	1500 Cooper St	Fort Worth	TX	Terminated
PED453300-25	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neuro Oncology	1500 Cooper St	Fort Worth	TX	Active
PED453300-26	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neuro Psych	1500 Cooper St	Fort Worth	TX	Terminated
PED453300-27	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Arlington Specialty Clinic - Cardiology Heart Center	3121 S. Center St	Arlington	TX	Active
PED453300-28	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Denton Specialty Clinic ~ Behavioral Health Clinic	3304 Colorado Blvd Suite #102	Denton	TX	Active
PED453300-29	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Southwest Specialty Clinic ~ Behavioral Health Clinic	6210 John Ryan Dr Suite #106	Fort Worth	TX	Active
PED453300-31	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Hurst Specialty Clinic ~ Behavioral Health Clinic	750 Mid Cities Boulevard	Hurst	TX	Active
PED453300-32	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Lewisville Specialty Clinic ~ Behavioral Health Clinic	401 N. Valley Pkwy, Suite #400	Lewisville	TX	Terminated
PED453300-35	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Ear Nose and Throat Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-36	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Teddy Bear Transport	124 Texas Way	Fort Worth	TX	Active
PED453300-37	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Specialty Clinic South ~ Partial Hospital Program	901 Seventh Ave	Fort Worth	TX	Terminated
PED453300-38	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Cardiology Outreach	1500 Cooper St	Fort Worth	TX	Terminated
PED453300-39	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ REACH Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-40	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Alexander Vision Center ~ Ophthalmology	321 S. Henderson St	Fort Worth	TX	Terminated
PED453300-41	Child	PED	COOK CHILDREN'S MEDICAL CENTER	McCart Neighborhood Clinic ~ Behavioral Health Clinic	6421 McCart Ave	Fort Worth	TX	Terminated
PED453300-42	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ NEST Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-43	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Mansfield / Behavioral Health Clinic	801 Matlock Road	Mansfield	TX	Active
PED453300-44	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Motion Analysis Lab	1401 W Pulaski St	Fort Worth	TX	Active
PED453300-45	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Dermatology	1500 Cooper St	Fort Worth	TX	Active
PED453300-46	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Sleep Medicine Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-47	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic - Genitourinary	1500 Cooper St	Fort Worth	TX	Active
PED453300-48	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Alliance Behavioral Health - Psych	10601 North Riverside Drive	Fort Worth	TX	Active
PED453300-49	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neurodiagnostic	1500 Cooper St	Fort Worth	TX	Active
PED453300-50	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neurosurgery	1500 Cooper St	Fort Worth	TX	Active
PED453300-51	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Immunology	1500 Cooper St	Fort Worth	TX	Active
PED453300-52	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Wound Care	1500 Cooper St	Fort Worth	TX	Active
PED453300-53	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Foster Health Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-54	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ CARE Team Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-55	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Trauma	1500 Cooper St	Fort Worth	TX	Active
PED453300-56	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Psychology- AYA	1500 Cooper St	Fort Worth	TX	Active
PED453300-57	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Ambulatory Surgery Center Anesthesia	1500 Cooper St	Fort Worth	TX	Active
PED453300-58	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Ambulatory Surgery Center Radiology	1500 Cooper St	Fort Worth	TX	Active
PED453300-59	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Prader-Willi Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-60	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Complex Care	1500 Cooper St	Fort Worth	TX	Active
PED453300-61	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic - Developmental Pediatrics	1500 Cooper St	Fort Worth	TX	Approved
PED453300-62	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic - Genetic Oncology	1500 Cooper St	Fort Worth	TX	Approved
PED453300-63	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic - Metabolic & Genetic Bone Health	1500 Cooper St	Fort Worth	TX	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	Hubbard, Ashlee Strategic Business Manager, Finance Cook Children's Medical Center 6823030423	Madrigal, Haydee Melanie Manager, 340B Program Cook Childrens Medical Center 6823031606	8/19/2024 1:12 PM
Details	Last Recertification Date	Update	Recertification		8/19/2024 1:12:40 PM	8/19/2024 1:12 PM
Details	Entity Subname	Update	Recertification	Dodson Specialty Clinic ~ - Prader-Willi Center	Dodson Specialty Clinic ~ Prader-Willi Center	8/19/2024 1:12 PM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Cychol, Nancy EVP, Hospital Services Cook Children's Medical Center 6828854340	4/2/2024 9:52 AM
Details	340B ID	Update	New Registration		PED453300-59	4/2/2024 9:52 AM
Details	Entity Name	Update	New Registration	COOK CHILDRENS MEDICAL CENTER	COOK CHILDREN'S MEDICAL CENTER	4/2/2024 9:52 AM
Details	Entity Subname	Update	New Registration	Dodson Specialty Clinic ~	Dodson Specialty Clinic ~ - Prader-Willi Center	4/2/2024 9:52 AM
Dates	Participating Approval Date	Update	New Registration		4/2/2024 9:52:22 AM	4/2/2024 9:52 AM
Details	State	Update	New Registration	Pending	Approved	4/2/2024 9:52 AM
Dates	Signed By Date	Update	New Registration		4/1/2024 4:23:02 PM	4/2/2024 9:52 AM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	4/2/2024 9:52 AM
Addresses	Main Address	Insert	New Registration		1500 Cooper St Fort Worth, TX 76104	4/1/2024 4:02 PM
Addresses	Billing Address	Insert	New Registration		Cook Children's Medical Center 801 7th Avenue Fort Worth, TX 76104	4/1/2024 4:02 PM
Addresses	Shipping Address	Insert	New Registration		Cook Children's Medical Center 801 7th Avenue Fort Worth, TX 76104	4/1/2024 4:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2024 4:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		021184901	4/1/2024 4:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/1/2024 4:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2024 4:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100702730A	4/1/2024 4:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	4/1/2024 4:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891765178	4/1/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	4/1/2024 4:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1750369203	4/1/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	4/1/2024 4:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891765178	4/1/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/1/2024 4:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1750369203	4/1/2024 4:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	4/1/2024 4:02 PM
Contacts	Authorizing Official	Insert	New Registration		Cychol, Nancy EVP, Hospital Services Cook Children's Medical Center 6828854340	4/1/2024 4:02 PM
Contacts	Primary Contact	Insert	New Registration		Hubbard, Ashlee Strategic Business Manager, Finance Cook Children's Medical Center 6823030423	4/1/2024 4:02 PM
Details	Assistance Received From Date	Insert	New Registration			4/1/2024 4:02 PM
Details	Assistance Received To Date	Insert	New Registration			4/1/2024 4:02 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2024 4:02 PM
Details	Grant Number	Insert	New Registration			4/1/2024 4:02 PM
Details	340B ID	Insert	New Registration			4/1/2024 4:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2024 4:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2024 4:02 PM
Details	Medicare Provider Number	Insert	New Registration		453300	4/1/2024 4:02 PM
Details	Entity Name	Insert	New Registration		COOK CHILDRENS MEDICAL CENTER	4/1/2024 4:02 PM
Details	NOFO Number	Insert	New Registration			4/1/2024 4:02 PM
Details	Program Code	Insert	New Registration		PED	4/1/2024 4:02 PM
Details	Entity Subname	Insert	New Registration		Dodson Specialty Clinic ~	4/1/2024 4:02 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2024 4:02 PM
Details	State	Insert	New Registration		Pending	4/1/2024 4:02 PM
Dates	Registration Date	Insert	New Registration		4/1/2024 4:02:32 PM	4/1/2024 4:02 PM
Dates	Signed By Date	Insert	New Registration			4/1/2024 4:02 PM
Dates	Start Date	Insert	New Registration			4/1/2024 4:02 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2024 4:02 PM
Terminations	Termination Date	Insert	New Registration			4/1/2024 4:02 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2024 4:02 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2024 4:02 PM