Covered Entity Details

DSH450388 METHODIST HOSPITAL (Active) - information as of 5/6/2025 10:59:20 PM

Main Details

Name

METHODIST HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH450388

Medicare Provider Number

450388

Additional Details

Current Program Status

Active

Registration Date

10/8/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/21/2024

Last Recertification Date

Contacts

Authorizing Official

Methodist Healthcare
Enrique Bernal, DCFO
(210) 575-0235

Primary Contact

Methodist Healthcare
Jeffrey Brian Mandel, VP of Pharmacy Services
(210) 954-7525

Addresses

Street Address

7700 FLOYD CURL DRIVE
SAN ANTONIO, TX 78229-3902

Billing Address

Methodist Hospital
1151 Enterprise Drive Suite 100
Coppell, TX 75019

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating Start Date10/1/2024, Termination 10/1/2024, Reinstatement 1/1/2025	10/21/2024

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	094154402	1124074273

Shipping Addresses

Shipping Address 1

Central Shared Services, LLC DBA San Antonio Supply Chain Srvc Center
5919 W Campus Drive
120
San Antonio, TX 78247

Shipping Address 2

Methodist Hospital Cellular Therapy Lab
4458 Medical Drive Ste 115
San Antonio, TX 78229

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/15/2025	07/01/2025	04/15/2025
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/15/2025	07/01/2025	04/15/2025
Contract Detail	ACCREDO HEALTH GROUP INC	9307 KIRBY DR		HOUSTON	TX	77054-2516	04/15/2025	07/01/2025	04/15/2025
Contract Detail	ACCREDO HEALTH GROUP INC	4343 W ROYAL LN STE 124		IRVING	TX	75063-2299	04/15/2025	07/01/2025	04/15/2025
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/15/2025	07/01/2025	04/15/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/15/2025	07/01/2025	04/15/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/15/2025	07/01/2025	04/15/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/15/2025	07/01/2025	04/15/2025
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 02263	22202 BULVERDE RD.	SAN ANTONIO	TX	78261	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07724	10225 WURZBACH RD	SAN ANTONIO	TX	78230	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01057	9140 GUILBEAU	SAN ANTONIO	TX	78250	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY # 5872	22135 IH-10 W	SAN ANTONIO	TX	78257	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY # 5858	15038 NACOGDOCHES RD.	SAN ANTONIO	TX	78247	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07808	4805 MEDICAL DR	SAN ANTONIO	TX	78229	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY # 7000	5301 ALAMO PARKWAY	SAN ANTONIO	TX	78253	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY #10540	9089 FAIR OAKS PKWY	FAIR OAKS RANCH	TX	78015	04/11/2025	07/01/2025	04/11/2025
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/11/2025	07/01/2025	04/11/2025
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/15/2025	07/01/2025	04/15/2025
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/15/2025	07/01/2025	04/15/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/15/2025	07/01/2025	04/15/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/15/2025	07/01/2025	04/15/2025
Contract Detail	HEB PHARMACY #019	19337 MCDONALD STREET	P.O. BOX 1929	LYTLE	TX	78052	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #025	925 10TH STREET		FLORESVILLE	TX	78114	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #026	4100 S. NEW BRAUNFELS		SAN ANTONIO	TX	78223	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #084	6818 S. ZARZAMORA		SAN ANTONIO	TX	78224	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #085	10718 POTRANCO RD.		SAN ANTONIO	TX	78251	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #102	8503 NW MILITARY HWY		SAN ANTONIO	TX	78230	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #108	20935 US HIGHWAY 281 N		SAN ANTONIO	TX	78258	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #164	15000 SAN PEDRO		SAN ANTONIO	TX	78232	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #191	4821 BROADWAY		SAN ANTONIO	TX	78209	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #205	721 CASTROVILLE ROAD		SAN ANTONIO	TX	78237	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #224	7951 GUILBEAU ROAD		SAN ANTONIO	TX	78250	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #230	14087 O'CONNOR		SAN ANTONIO	TX	78247	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #235	9255 FM 471 WEST		SAN ANTONIO	TX	78250	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #294	6580 FM 78		SAN ANTONIO	TX	78244	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #384	6030 MONTGOMERY RD		SAN ANTONIO	TX	78239	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #385	300 W. OLMOS DR		SAN ANTONIO	TX	78212	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #415	17460 IH 35 NORTH		SCHERTZ	TX	78154	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #427	735 SW MILITARY DR		SAN ANTONIO	TX	78221	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #441	227 E. MAIN		UVALDE	TX	78801	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #444	3323 SE MILITARY DR.		SAN ANTONIO	TX	78223	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #463	1150 NW LOOP 1604		SAN ANTONIO	TX	78248	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #480	9900 WURZBACH ROAD		SAN ANTONIO	TX	78230	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #555	910 KITTY HAWK		UNIVERSAL CITY	TX	78148	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #556	2118 FREDERICKSBURG RD		SAN ANTONIO	TX	78201	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #566	24-165 I-10 W	SUITE 300	SAN ANTONIO	TX	78257	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #567	999 E. BASSE	SUITE 150	SAN ANTONIO	TX	78209	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #585	1520 AUSTIN HWY		SAN ANTONIO	TX	78218	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #612	14414 US HWY 87 WEST		LAVERNIA	TX	78121	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #613	8219 MARBACH RD		SAN ANTONIO	TX	78227	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #618	5910 BABCOCK		SAN ANTONIO	TX	78240	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #621	420 WEST BANDERA		BOERNE	TX	78006	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #622	20725 HWY 46 WEST		SPRING BRANCH	TX	78070	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #623	9238 NORTH LOOP 1604 WEST		SAN ANTONIO	TX	78249	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #658	23635 WILDERNESS OAK		SAN ANTONIO	TX	78258	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #678	302 VALLEY HI DR		SAN ANTONIO	TX	78227	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #732	17238 BULVERDE RD		SAN ANTONIO	TX	78247	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY #733	12125 ALAMO RANCH PKWY		SAN ANTONIO	TX	78253	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB PHARMACY WAREHOUSE 208	H-E-B, LP	5311 DIETRICH RD STE 100	SAN ANTONIO	TX	78219	04/11/2025	07/01/2025	04/11/2025
Contract Detail	HEB SPECIALTY PHARMACY #701	3503 FREDERICKSBURG RD	STE 450	SAN ANTONIO	TX	78201	04/11/2025	07/01/2025	04/11/2025
Contract Detail	ONCO360	SINA DRUG, LLC	4700 W SAM HOUSTON PKWY N STE 150	HOUSTON	TX	77041	04/11/2025	07/01/2025	04/11/2025
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/11/2025	07/01/2025	04/11/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/11/2025	07/01/2025	04/11/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/11/2025	07/01/2025	04/11/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2859	7950 FLOYD CURL DR. STE #106	SAN ANTONIO	TX	78229	04/11/2025	07/01/2025	04/11/2025
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09180	11103 W MILITARY DR	SAN ANTONIO	TX	78251	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04934	6017 INGRAM ROAD	SAN ANTONIO	TX	78238	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07923	22114 BULVERDE ROAD	SAN ANTONIO	TX	78259	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12520	300 E. HOUSTON ST.	SAN ANTONIO	TX	78205-1816	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16485	7302 LOUIS PASTEUR DR STE 104	SAN ANTONIO	TX	78229	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13940	26482 US HIGHWAY 281 N	SAN ANTONIO	TX	78258	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04160	2200 E. HOUSTON ST	SAN ANTONIO	TX	78202	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03368	1581 AUSTIN HIGHWAY	SAN ANTONIO	TX	78218	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03141	1105 GOLIAD ROAD	SAN ANTONIO	TX	78223	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05963	3801 FM 3009	SCHERTZ	TX	78154	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02944	7423 BROADWAY ST	SAN ANTONIO	TX	78209	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06335	14025 NACOGDOCHES RD	SAN ANTONIO	TX	78247-1918	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02943	2710 NOGALITOS	SAN ANTONIO	TX	78225	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21214	660 N MAIN AVE STE 101	SAN ANTONIO	TX	78205	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11521	10858 WURZBACH RD.	SAN ANTONIO	TX	78230-2434	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05964	3401 SAN PEDRO	SAN ANTONIO	TX	78212	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11276	502 NEW VALLEY HI	SAN ANTONIO	TX	78227	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03996	5760 WALZEM RD	WINDCREST	TX	78218	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA:WALGREENS #15621	25215 INTERSTATE10 W	SAN ANTONIO	TX	78257	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03140	410 W. CYPRESS ST.	SAN ANTONIO	TX	78212	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09697	10003 W LOOP 1604 N	SAN ANTONIO	TX	78254	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15932	901 BITTERS RD	SAN ANTONIO	TX	78216	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03505	6635 BANDERA RD	SAN ANTONIO	TX	78238	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02458	7802 WURZBACH ROAD	SAN ANTONIO	TX	78229	04/11/2025	07/01/2025	04/11/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02755	3065 RIGSBY AVE	SAN ANTONIO	TX	78222	04/11/2025	07/01/2025	04/11/2025
Contract Detail	Walgreens MFC #21373	4100 Dale Earnhardt Way	200	Northlake	TX	76262	04/11/2025	07/01/2025	04/11/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH450388A	Child	DSH	METHODIST HOSPITAL	25164 - Methodist Boerne Emergency - FSED - Boerne	134 MENGER SPGS	Boerne	TX	Active
DSH450388AA	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Special Procedure - Operating Room	12412 Judson Rd	Live Oak	TX	Active
DSH450388AB	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Urodynamics - Urology	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388AC	Child	DSH	METHODIST HOSPITAL	27901 Methodist FSER Potranco - FSER Potranco	9211 POTRANCO RD	San Antonio	TX	Active
DSH450388AD	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Surgery - Operating Room	12412 Judson Rd	Live Oak	TX	Active
DSH450388AE	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Hemo Dyalisis - Renal Dialysis	6700 West IH-10	San Antonio	TX	Active
DSH450388AF	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - GI Lab - Gastrointestinal Services	1310 McCullough Ave	San Antonio	TX	Active
DSH450388AG	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - MRI - MRI	6700 West IH-10	San Antonio	TX	Active
DSH450388AH	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Cardiac Cath - Cardiac Catheterization	6700 West IH-10	San Antonio	TX	Active
DSH450388AJ	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Liver Organ - Transplant	8201 Ewing Halsell	San Antonio	TX	Active
DSH450388AK	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Cardiac Ultrasound - Electrocardiology	6700 West IH-10	San Antonio	TX	Active
DSH450388AL	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Dialysis - Renal Dialysis	12412 Judson Rd	Live Oak	TX	Active
DSH450388AM	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Radiology - Radiology	12412 Judson Rd	Live Oak	TX	Active
DSH450388AN	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - OP CARD 1 - Cardiology	4411 Medical Dr	San Antonio	TX	Active
DSH450388AP	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Radiology - Radiology	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388AQ	Child	DSH	METHODIST HOSPITAL	27903 Methodist FSER Helotes - FSER Helotes	12285 BANDERA RD	Helotes	TX	Active
DSH450388AR	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Cardiac Cath - Cardiac Catheterization	12412 Judson Rd	Live Oak	TX	Active
DSH450388AS	Child	DSH	METHODIST HOSPITAL	27905 Methodist FSER Nacogdoches - FSER Nacogdoches	13434 Nacogdoches Rd	San Antonio	TX	Active
DSH450388AT	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Liver Post Transplant - Transplant	8201 Ewing Halsell	San Antonio	TX	Active
DSH450388AU	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan Surgery - Operating Room	6700 West IH-10	San Antonio	TX	Active
DSH450388AV	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Non Invasive - Cardiology	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388AW	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Recovery - Recovery Room	6700 West IH-10	San Antonio	TX	Active
DSH450388AX	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - CT Scan - CT Scan	1310 McCullough Ave	San Antonio	TX	Active
DSH450388AY	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Nuclear Med - Nuclear Medicine	12412 Judson Rd	Live Oak	TX	Active
DSH450388AZ	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Day Operating - Recovery Room	6700 West IH-10	San Antonio	TX	Active
DSH450388B	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - PB NM/ECHO - Cardiology	6700 West IH-10	San Antonio	TX	Active
DSH450388BA	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Nuclear Medicine - Nuclear Medicine	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388BB	Child	DSH	METHODIST HOSPITAL	25164 - Boerne ER IV Therapy - IV Therapy	134 MENGER SPGS	Boerne	TX	Active
DSH450388BC	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - Aortic Clinic - Aortic Clinic	4499 Medical Dr	San Antonio	TX	Active
DSH450388BD	Child	DSH	METHODIST HOSPITAL	26664 Metropolitan Methodist - Alamo Heights FSED - FSER Alamo Heights	250 E Basse Road	San Antonio	TX	Active
DSH450388BE	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - Pedi Specialty Clinic - Pedi Specialty Clinic	4410 Medical Dr	San Antonio	TX	Active
DSH450388BF	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - MRI - MRI	12412 Judson Rd	Live Oak	TX	Active
DSH450388BG	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Renal Post Transplant - Transplant	8201 Ewing Halsell	San Antonio	TX	Active
DSH450388BH	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Recovery - Recovery Room	12412 Judson Rd	Live Oak	TX	Active
DSH450388BJ	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Phase 2 Recovery - Recovery Room	1310 McCullough Ave	San Antonio	TX	Active
DSH450388BK	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - Outpatient Oncology Rehab - Oncology Rehab	4410 Medical Dr	San Antonio	TX	Active
DSH450388BL	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Radiology - Anesthesia	1310 McCullough Ave	San Antonio	TX	Active
DSH450388BM	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - NB Echo Nm - Cardiology	1583 Common St	New Braunfels	TX	Active
DSH450388BN	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Recovery Room - Recovery Room	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388BP	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - CITC - Infusion Therapy Services	4410 Medical Dr	San Antonio	TX	Active
DSH450388BQ	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Nuclear Med - Nuclear Medicine	1310 McCullough Ave	San Antonio	TX	Active
DSH450388BR	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Infuse OP - Infusion Therapy Services	1310 McCullough Ave	San Antonio	TX	Active
DSH450388BS	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - Heart Post Transplant Clinic - Heart Post Transplant Clinic	7726 Louis Pasteur Dr	San Antonio	TX	Active
DSH450388BT	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - CT Scan - CT Scan	6700 West IH-10	San Antonio	TX	Active
DSH450388BU	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - Cardiac Rehab - Cardiology	4499 Medical Dr	San Antonio	TX	Active
DSH450388BV	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Labor and Delivery - Delivery Room and Labor Room	1310 McCullough Ave	San Antonio	TX	Active
DSH450388BW	Child	DSH	METHODIST HOSPITAL	27902 - Methodist DeZavala IV Therapy - IV Therapy	12805 W I-10	San Antonio	TX	Active
DSH450388BX	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Renal Transplant - Transplant	8201 Ewing Halsell	San Antonio	TX	Active
DSH450388BY	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Surgery - Operating Room	1310 McCullough Ave	San Antonio	TX	Active
DSH450388BZ	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - PB Nuclear Med Echo - Cardiology	1100 McCullough Ave	San Antonio	TX	Active
DSH450388C	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - MRI - Radiology	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388CA	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - GI Lab - Gastrointestinal Services	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388CB	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Cardiac Cath - Cardiac Catheterization	1310 McCullough Ave	San Antonio	TX	Active
DSH450388CC	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital PB Cardiol - PB Cardiol	4410 Medical Dr	San Antonio	TX	Active
DSH450388CD	Child	DSH	METHODIST HOSPITAL	27902 - Methodist FSER De Zavala - FSER De Zavala	12805 W I-10	San Antonio	TX	Active
DSH450388CE	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - G.I. Lab - Gastrointestinal Services	12412 Judson Rd	Live Oak	TX	Active
DSH450388CF	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Phase 2 Recovery - Recovery Room	12412 Judson Rd	Live Oak	TX	Active
DSH450388CG	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Emergency - Emergency Services	12412 Judson Rd	Live Oak	TX	Active
DSH450388CH	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - CT Scan - CT Scan	12412 Judson Rd	Live Oak	TX	Active
DSH450388CJ	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Radiology - Radiology	6700 West IH-10	San Antonio	TX	Active
DSH450388CK	Child	DSH	METHODIST HOSPITAL	28436 Methodist ER City Base - Emergency - FSER City Base	3154 SE Military Dr	San Antonio	TX	Active
DSH450388CL	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Blood Bank - Blood Bank	6700 West IH-10	San Antonio	TX	Active
DSH450388CM	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Cardiac Cath - Cardiac Catheterization	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388CN	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Special Procedures - Special Procedures	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388CP	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - PB NM ECHO - Cardiology	12709 Topperwein Rd	Live Oak	TX	Active
DSH450388CQ	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Non Invasive - Electrocardiology	12412 Judson Rd	Live Oak	TX	Active
DSH450388CR	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - Adult Congenital Heart Disease - Congenital Heart Disease	4410 Medical Dr	San Antonio	TX	Terminated
DSH450388CS	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Anesthesia - Anesthesia	6700 West IH-10	San Antonio	TX	Active
DSH450388CT	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Emergency Services - Emergency Services	1310 McCullough Ave	San Antonio	TX	Active
DSH450388CU	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Special Procedures - Operating Room	1310 McCullough Ave	San Antonio	TX	Active
DSH450388CV	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Dialysis - Renal Dialysis	1310 McCullough Ave	San Antonio	TX	Active
DSH450388CW	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Bariatric - BARIATRIC CLINIC	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388CX	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- IV Therapy - DRUGS CHARGED TO PATIENTS	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388CY	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Surg Implnt - IMPL. DEV. CHARGED TO PATIENTS	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388CZ	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Card Ultra - ELECTROCARDIOLOGY	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388D	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - OP Cardiac Imaging - Cardiology	1200 Brooklyn Ave	San Antonio	TX	Active
DSH450388DA	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- EKG - ELECTROCARDIOLOGY	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DB	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- RES Therapy - RESPIRATORY THERAPY	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DC	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Cardiac CAT - CARDIAC CATHETERIZATION	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DD	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- CAT Scan - CT SCAN	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DE	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Ultrasound - ULTRA SOUND	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DF	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Rad Diag - RADIOLOGY-DIAGNOSTIC	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DG	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Anesthesia - ANESTHESIOLOGY	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DH	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Short Stay - RECOVERY ROOM	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DJ	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Recovery - RECOVERY ROOM	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DK	Child	DSH	METHODIST HOSPITAL	27540 Methodist Hospital Landmark Surgery - Operating Room	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DL	Child	DSH	METHODIST HOSPITAL	27540 Methodist Hospital Landmark - Emergency Services	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DM	Child	DSH	METHODIST HOSPITAL	26664- METROPOLITAN METHODIST EMER- Alamo Heights FSED Blood Bank - BLOOD STORING, PROCESSING & TRANS.	250 E Basse Road	San Antonio	TX	Active
DSH450388DN	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Physical - PHYSICAL THERAPY	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DP	Child	DSH	METHODIST HOSPITAL	27540- Methodist Hospital Landmark- Blood Bank - BLOOD STORING, PROCESSING & TRANS.	5510 Presidio Parkway	San Antonio	TX	Active
DSH450388DQ	Child	DSH	METHODIST HOSPITAL	39385- Methodist Hospital- PSOT Clinic - PEDIATRIC SPEC TX CLINIC	4410 Medical Drive	San Antonio	TX	Active
DSH450388E	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Post Anesthesia - Recovery Room	1310 McCullough Ave	San Antonio	TX	Active
DSH450388F	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - RT - Respiratory	1310 McCullough Ave	San Antonio	TX	Active
DSH450388G	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Nuclear Medicine - Nuclear Medicine	6700 West IH-10	San Antonio	TX	Active
DSH450388H	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Anesthesia OR - Anesthesia	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388J	Child	DSH	METHODIST HOSPITAL	27440 Methodist ER New Braunfels - FSER New Braunfels	1850 W TX-46	New Braunfels	TX	Active
DSH450388K	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Surgery - Operating Room	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388L	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital - Wound Care - Wound Care	4499 Medical Dr	San Antonio	TX	Active
DSH450388M	Child	DSH	METHODIST HOSPITAL	34385 Methodist Hospital Northeast - Ansthesia - Anesthesia	12412 Judson Rd	Live Oak	TX	Active
DSH450388N	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Pulmonary Diagnostics - Pulmonary	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388P	Child	DSH	METHODIST HOSPITAL	27536 Methodist Converse Emergency - FSER Converse	6402 Mallard Mdw	San Antonio	TX	Active
DSH450388Q	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Pancreas Transplant - Transplant	8201 Ewing Halsell	San Antonio	TX	Active
DSH450388R	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - Short Stay - Recovery Room	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388S	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - RT - Respiratory	6700 West IH-10	San Antonio	TX	Active
DSH450388T	Child	DSH	METHODIST HOSPITAL	34335 Methodist Hospital Specialty & Transplant - ER - Emergency Services	8026 Floyd Curl Dr.	San Antonio	TX	Active
DSH450388U	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Non-Invasive - Electrocardiology	1310 McCullough Ave	San Antonio	TX	Active
DSH450388V	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Neuro Vascular - Electrocardiology	1310 McCullough Ave	San Antonio	TX	Active
DSH450388W	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - MRI - MRI	1310 McCullough Ave	San Antonio	TX	Active
DSH450388X	Child	DSH	METHODIST HOSPITAL	26109 Methodist Hospital TexSan - Emergency - Emergency Services	6700 West IH-10	San Antonio	TX	Active
DSH450388Y	Child	DSH	METHODIST HOSPITAL	34392 Methodist Hospital Metropolitan - Anesthesia - Anesthesia	1310 McCullough Ave	San Antonio	TX	Active
DSH450388Z	Child	DSH	METHODIST HOSPITAL	39385 Methodist Hospital Diabetic Foot and Ankle Institute - DIABETIC FOOT AND ANKLE INST	4330 MEDICAL DR	San Antonio	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Update	Change Request	Central Shared Services, LLC DBA San Antonio Supply Chain Srvc Center 5919 W Campus Rd 120 San Antonio, TX 78247	Central Shared Services, LLC DBA San Antonio Supply Chain Srvc Center 5919 W Campus Drive 120 San Antonio, TX 78247	4/15/2025 6:57 AM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Addresses	Shipping Address	Insert	Change Request		Methodist Hospital Cellular Therapy Lab 4458 Medical Drive Ste 115 San Antonio, TX 78229	12/12/2024 1:36 PM
Addresses	Billing Address	Insert	Reinstatement		Methodist Hospital 1151 Enterprise Drive Suite 100 Coppell, TX 75019	10/21/2024 12:20 PM
Addresses	Shipping Address	Insert	Reinstatement		Central Shared Services, LLC DBA San Antonio Supply Chain Srvc Center 5919 W Campus Rd 120 San Antonio, TX 78247	10/21/2024 12:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	10/21/2024 12:20 PM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		094154402	10/21/2024 12:20 PM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		TX	10/21/2024 12:20 PM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1124074273	10/21/2024 12:20 PM
Medicaid Billing	NPI: State	Insert	Reinstatement		TX	10/21/2024 12:20 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	10/1/2024 12:00:00 AM		10/21/2024 12:20 PM
Dates	Participating Approval Date	Update	Reinstatement	9/5/2024 6:02:03 AM	10/21/2024 12:20:23 PM	10/21/2024 12:20 PM
Details	State	Update	Reinstatement	Terminated	Approved	10/21/2024 12:20 PM
Dates	Registration Date	Update	Reinstatement	7/12/2024 3:49:26 PM	10/8/2024 2:45:37 PM	10/21/2024 12:20 PM
Dates	Signed By Date	Update	Reinstatement	7/12/2024 6:05:16 PM	10/18/2024 10:35:09 AM	10/21/2024 12:20 PM
Dates	Start Date	Update	Reinstatement	10/1/2024 12:00:00 AM	1/1/2025 12:00:00 AM	10/21/2024 12:20 PM
Terminations	Termination Date	Update	Reinstatement	10/1/2024 12:00:00 AM		10/21/2024 12:20 PM
Terminations	Termination Effective Date	Update	Reinstatement	10/1/2024 12:00:00 AM		10/21/2024 12:20 PM
Terminations	Termination Reason	Update	Reinstatement	Business decision by the Covered Entity		10/21/2024 12:20 PM
Details	Comments Public	Insert	Reinstatement		Participating Start Date10/1/2024, Termination 10/1/2024, Reinstatement 1/1/2025	10/21/2024 11:28 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/1/2024 12:00:00 AM	9/20/2024 1:48 PM
Details	State	Update	Termination Request	Approved	To Be Terminated	9/20/2024 1:48 PM
Terminations	Termination Date	Update	Termination Request		10/1/2024 12:00:00 AM	9/20/2024 1:48 PM
Terminations	Termination Effective Date	Update	Termination Request		10/1/2024 12:00:00 AM	9/20/2024 1:48 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	9/20/2024 1:48 PM
Contacts	Signed By	Insert	New Registration		Bernal, Enrique DCFO Methodist Healthcare 2105750235	9/5/2024 6:02 AM
Details	340B ID	Update	New Registration		DSH450388	9/5/2024 6:02 AM
Dates	Participating Approval Date	Update	New Registration		9/5/2024 6:02:03 AM	9/5/2024 6:02 AM
Details	State	Update	New Registration	Pending	Approved	9/5/2024 6:02 AM
Dates	Signed By Date	Update	New Registration		7/12/2024 6:05:16 PM	9/5/2024 6:02 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	9/5/2024 6:02 AM
Addresses	Main Address	Insert	New Registration		7700 FLOYD CURL DRIVE SAN ANTONIO, TX 78229-3902	7/12/2024 3:49 PM
Contacts	Primary Contact	Insert	New Registration		Mandel, Jeffrey Brian VP of Pharmacy Services Methodist Healthcare 2109547525	7/12/2024 3:49 PM
Contacts	Authorizing Official	Insert	New Registration		Bernal, Enrique DCFO Methodist Healthcare 2105750235	7/12/2024 3:49 PM
Details	Assistance Received From Date	Insert	New Registration			7/12/2024 3:49 PM
Details	Assistance Received To Date	Insert	New Registration			7/12/2024 3:49 PM
Details	Last Recertification Date	Insert	New Registration			7/12/2024 3:49 PM
Details	Grant Number	Insert	New Registration			7/12/2024 3:49 PM
Details	340B ID	Insert	New Registration			7/12/2024 3:49 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/12/2024 3:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/12/2024 3:49 PM
Details	Medicare Provider Number	Insert	New Registration		450388	7/12/2024 3:49 PM
Details	Entity Name	Insert	New Registration		METHODIST HOSPITAL	7/12/2024 3:49 PM
Details	NOFO Number	Insert	New Registration			7/12/2024 3:49 PM
Details	Program Code	Insert	New Registration		DSH	7/12/2024 3:49 PM
Details	Entity Subname	Insert	New Registration			7/12/2024 3:49 PM
Dates	Participating Approval Date	Insert	New Registration			7/12/2024 3:49 PM
Details	State	Insert	New Registration		Pending	7/12/2024 3:49 PM
Dates	Registration Date	Insert	New Registration		7/12/2024 3:49:26 PM	7/12/2024 3:49 PM
Dates	Signed By Date	Insert	New Registration			7/12/2024 3:49 PM
Dates	Start Date	Insert	New Registration			7/12/2024 3:49 PM
Terminations	Termination Comments	Insert	New Registration			7/12/2024 3:49 PM
Terminations	Termination Date	Insert	New Registration			7/12/2024 3:49 PM
Terminations	Termination Effective Date	Insert	New Registration			7/12/2024 3:49 PM
Terminations	Termination Reason	Insert	New Registration			7/12/2024 3:49 PM