Covered Entity Details

DSH670077D HOUSTON METHODIST WEST HOSPITAL (Active) - information as of 4/29/2025 11:54:04 PM

Main Details

Name

HOUSTON METHODIST WEST HOSPITAL

Subdivision Name

Houston Methodist ECC at Cinco Ranch Radiology - Radiology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH670077D

Medicare Provider Number

670077

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/2/2024

Last Recertification Date

Contacts

Authorizing Official

Houston Methodist West Hospital
Kyle R Stanzel, VP & Chief Operating Officer
(832) 522-0300

Primary Contact

Houston Methodist
Daniel Metzen, System Director of Pharmacy
(713) 441-2141

Addresses

Street Address

26000 FM 1093 RD
Richmond, TX 77046-7857

Billing Address

Houston Methodist West Hospital
18500 KATY FWY
Houston, TX 77094-1110

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		1083937593

Shipping Addresses

Shipping Address 1

Houston Methodist West Hospital
18500 KATY FWY
Houston, TX 77094-1110

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
DSH670077A	Child	DSH	HOUSTON METHODIST WEST HOSPITAL	Houston Methodist Emergency Care CE	26000 FM 1093 RD	Richmond	TX	Active
DSH670077B	Child	DSH	HOUSTON METHODIST WEST HOSPITAL	HOUSTON METHODIST NEAL CANCER CENTER	18400 KATY FWY	HOUSTON	TX	Active
DSH670077C	Child	DSH	HOUSTON METHODIST WEST HOSPITAL	HOUSTON METHODIST WEST BREAST CENTE - Breast Center-Radiology Diagnostic	18300 KATY FWY	HOUSTON	TX	Active
DSH670077D	Child	DSH	HOUSTON METHODIST WEST HOSPITAL	Houston Methodist ECC at Cinco Ranch Radiology - Radiology	26000 FM 1093 RD	Richmond	TX	Active
DSH670077E	Child	DSH	HOUSTON METHODIST WEST HOSPITAL	Infusion Center - Infusion Center	18400 Katy Fwy, Suite 200	Houston	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Stanzel, Kyle R VP & Chief Operating Officer Houston Methodist West Hospital 8325220300	8/2/2024 9:51 AM
Details	340B ID	Update	New Registration		DSH670077D	8/2/2024 9:51 AM
Details	Entity Name	Update	New Registration	METHODIST WEST HOUSTON HOSPITAL	HOUSTON METHODIST WEST HOSPITAL	8/2/2024 9:51 AM
Details	Entity Subname	Update	New Registration	Houston Methodist ECC at Cinco Ranch Radiology	Houston Methodist ECC at Cinco Ranch Radiology - Radiology	8/2/2024 9:51 AM
Dates	Participating Approval Date	Update	New Registration		8/2/2024 9:51:24 AM	8/2/2024 9:51 AM
Details	State	Update	New Registration	Pending	Approved	8/2/2024 9:51 AM
Dates	Signed By Date	Update	New Registration		8/2/2024 8:00:43 AM	8/2/2024 9:51 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/2/2024 9:51 AM
Addresses	Main Address	Insert	New Registration		26000 FM 1093 RD Richmond, TX 77046-7857	7/11/2024 4:00 PM
Addresses	Billing Address	Insert	New Registration		Houston Methodist West Hospital 18500 KATY FWY Houston, TX 77094-1110	7/11/2024 4:00 PM
Addresses	Shipping Address	Insert	New Registration		Houston Methodist West Hospital 18500 KATY FWY Houston, TX 77094-1110	7/11/2024 4:00 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083937593	7/11/2024 4:00 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	7/11/2024 4:00 PM
Contacts	Authorizing Official	Insert	New Registration		Stanzel, Kyle R VP & Chief Operating Officer Houston Methodist West Hospital 8325220300	7/11/2024 4:00 PM
Contacts	Primary Contact	Insert	New Registration		Metzen, Daniel System Director of Pharmacy Houston Methodist 7134412141	7/11/2024 4:00 PM
Details	Assistance Received From Date	Insert	New Registration			7/11/2024 4:00 PM
Details	Assistance Received To Date	Insert	New Registration			7/11/2024 4:00 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2024 4:00 PM
Details	Grant Number	Insert	New Registration			7/11/2024 4:00 PM
Details	340B ID	Insert	New Registration			7/11/2024 4:00 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2024 4:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2024 4:00 PM
Details	Medicare Provider Number	Insert	New Registration		670077	7/11/2024 4:00 PM
Details	Entity Name	Insert	New Registration		METHODIST WEST HOUSTON HOSPITAL	7/11/2024 4:00 PM
Details	NOFO Number	Insert	New Registration			7/11/2024 4:00 PM
Details	Program Code	Insert	New Registration		DSH	7/11/2024 4:00 PM
Details	Entity Subname	Insert	New Registration		Houston Methodist ECC at Cinco Ranch Radiology	7/11/2024 4:00 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2024 4:00 PM
Details	State	Insert	New Registration		Pending	7/11/2024 4:00 PM
Dates	Registration Date	Insert	New Registration		7/11/2024 4:00:18 PM	7/11/2024 4:00 PM
Dates	Signed By Date	Insert	New Registration			7/11/2024 4:00 PM
Dates	Start Date	Insert	New Registration			7/11/2024 4:00 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2024 4:00 PM
Terminations	Termination Date	Insert	New Registration			7/11/2024 4:00 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2024 4:00 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2024 4:00 PM