Covered Entity Details

RRC450801-00 CHRISTUS ST MICHAEL (Terminated) - information as of 4/29/2025 10:37:15 PM

Main Details

Name

CHRISTUS ST MICHAEL

Subdivision Name

Type

Rural Referral Center

Rural

340B ID

RRC450801-00

Medicare Provider Number

450801

Additional Details

Current Program Status

Terminated

Registration Date

10/7/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/23/2024

Last Recertification Date

Termination Date
Termination Reason

1/1/2025
Other

Contacts

Authorizing Official

CHRISTUS St. Michael
Jason Adams, President
(903) 614-2001

Primary Contact

CHRISTUS St Michael
Carly Armstrong, Coordinator Pharmacy 340B Program
(903) 614-2929

Addresses

Street Address

2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503

Billing Address

CHRISTUS ST MICHAEL
2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503

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	020976901,020976902,020976903,094644402,094353202	1295736734,1467591396,1689702334
LA	1733229	1295736734,1467591396,1689702334
AR	146008105	1295736734

Shipping Addresses

Shipping Address 1

CHRISTUS St. Michael - Healthcare Center Pharmacy
2604 St. Michael Drive, Suite 200
Texarkana, TX 75503

Shipping Address 2

CHRISTUS ST MICHAEL
2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	ACCREDO HEALTH GROUP INC	4343 W ROYAL LN STE 124		IRVING	TX	75063-2299	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	ALBERTSON'S, LLC	ALBERTSONS PHARMACY #0611	3710 STATE LINE AVE	TEXARKANA	AR	71854	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	ALBERTSONS LLC	SAVON PHARMACY #135	4415 W. 7TH	TEXARKANA	TX	75501	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	AMERITA	CENTRAL LINE INFUSION DALLAS	8080 TRISTAR DR STE 120	IRVING	TX	75063-2823	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	ARKANSAS CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10019	3908 N. STATELINE AVE.	TEXARKANA	AR	71854	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CHRISTUS SPECIALTY PHARMACY	MOTHER FRANCES REGIONAL HEALTH CARE CTR	800 E DAWSON ST STE 100	TYLER	TX	75701-2036	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CVS PHARMACY, INC.	CVS PHARMACY # 16933	102 RICHMOND RANCH RD	TEXARKANA	TX	75503	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY # 1368	101 LOOP 59 NORTH	ATLANTA	TX	75551	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY # 10055	1901 RICHMOND RD.	TEXARKANA	TX	75503	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	GLENWOOD PHARMACY	1400 COLLEGE DRIVE		TEXARKANA	TX	75503	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM INFUSION SERVICES 500 INC	1893 GENERAL GEORGE PATTON DR	# 100	FRANKLIN	TN	37067-2655	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2751	426 S. HENDERSON STREET	FORT WORTH	TX	76104	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	SUPER D DRUGS ACQUISITION CO.	DBA: WALGREENS #15790	191 WEST MAIN	ASHDOWN	AR	71822	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WAL-MART PHARMACY 10-0226	201 U.S. HWY. 59 LOOP		ATLANTA	TX	75551	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06195	4415 N STATELINE AVE	TEXARKANA	TX	75503	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06525	1902 RICHMOND ROAD	TEXARKANA	TX	75503-2425	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10418	1004 W COMMERCE BLVD	HOPE	AR	71801	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	Walgreens #21373	Walgreens Central Fill #21373	4100 Dale Earnhardt Way STE 200	Northlake	TX	76262	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALMART PHARMACY #10-4371	3520 RICHMOND ROAD		TEXARKANA	TX	75503	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALMART PHARMACY 10-4367	3302 SUMMERHILL ROAD		TEXARKANA	TX	75503	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALMART PHARMACY 10-4373	200 WAKE VILLAGE RD.		WAKE VILLAGE	TX	75501	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/23/2024	01/01/2025	01/01/2025	01/01/2025
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/23/2024	01/01/2025	01/01/2025	01/01/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
RRC450801-01	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Non-Oncology Outpatient Infusion	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-02	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Phys Thrpy	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-03	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Cat Scanner	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-04	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - MRI	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-05	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Ultrasound	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-06	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Mammography	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-07	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Blood Bank	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-08	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Sleep Lab	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-09	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Radiology Diag	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-10	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Wound Care	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-11	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Reference Lab	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-12	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - TOT Therapy	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-13	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Chemistry	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-14	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Microbiology	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-15	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Hematology	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-16	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Lab General	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-17	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Emergency Services	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-18	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL SLEEP LAB - Sleep Lab	2604 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-19	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL OUTPATIENT IMAG - Imaging	2500 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-20	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL NEUROLOGY CLINI - Neurology	5002 COWHORN CREEK RD	TEXARKANA	TX	Terminated
RRC450801-21	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL CARDIOVASCULAR - Cardiovascular and Thoracic Surgery Clinic	2604 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-22	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL ORTHOPEDIC SURG - Orthopedic Surgery	2602 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-23	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL PAIN MANAGEMENT - Pain Management	2604 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-24	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL ENDOCRINOLOGY - Endocrinology	2602 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-25	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS HEALTH ARK-LA-TEX - W. Temple Cancer Treatment Center-Rad Therapy	2604 SAINT MICHAEL DR, FL 1	TEXARKANA	TX	Terminated
RRC450801-26	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS HEALTH ARK-LA-TEX - CHRISTUS St. Michael Oncology Clinic W - Infusion	5002 COWHORN CREEK RD, STE 3205	TEXARKANA	TX	Terminated
RRC450801-27	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL ONCOLOGY CLINIC - Clinic	2602 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-28	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Resp Thrpy	1007 S WILLIAM ST	ATLANTA	TX	Terminated
RRC450801-29	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL OUTPATIENT INFU - Outpatient Infusion	2602 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-30	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS HEALTH ARK-LA-TEX - W. Temple Cancer Treatment Center-Chemo	2604 SAINT MICHAEL DR, FL 1	TEXARKANA	TX	Terminated
RRC450801-31	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL NEUROSURGERY - Clinic	2604 SAINT MICHAEL DR	TEXARKANA	TX	Terminated
RRC450801-32	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS HEALTH ARK-LA-TEX - CHRISTUS St. Michael Oncology Clinic	5002 COWHORN CREEK RD, STE 3205	TEXARKANA	TX	Terminated
RRC450801-33	Child	RRC	CHRISTUS ST MICHAEL	CHRISTUS ST MICHAEL HOSPITAL - Atlanta - Med Surg	1007 S WILLIAM ST	ATLANTA	TX	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/1/2024 12:00:00 AM	11/12/2024 10:52 AM
Details	State	Update	Termination Request	Approved	To Be Terminated	11/12/2024 10:52 AM
Terminations	Termination Comments	Update	Termination Request		Location will be able to maintain DSH status and is terminating the RRC change and requests the DSH be reactivated.	11/12/2024 10:52 AM
Terminations	Termination Date	Update	Termination Request		1/1/2025 12:00:00 AM	11/12/2024 10:52 AM
Terminations	Termination Effective Date	Update	Termination Request		10/1/2024 12:00:00 AM	11/12/2024 10:52 AM
Terminations	Termination Reason	Update	Termination Request		Other	11/12/2024 10:52 AM
Contacts	Signed By	Insert	Hospital Type Change Request		Adams, Jason President CHRISTUS St. Michael 9036142001	10/23/2024 10:34 AM
Details	340B ID	Update	Hospital Type Change Request		RRC450801-00	10/23/2024 10:34 AM
Dates	Participating Approval Date	Update	Hospital Type Change Request		10/23/2024 10:34:13 AM	10/23/2024 10:34 AM
Details	State	Update	Hospital Type Change Request	Pending	Approved	10/23/2024 10:34 AM
Dates	Signed By Date	Update	Hospital Type Change Request		10/9/2024 2:50:23 PM	10/23/2024 10:34 AM
Dates	Start Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	10/23/2024 10:34 AM
Addresses	Main Address	Insert	Hospital Type Change Request		2600 ST MICHAEL DRIVE TEXARKANA, TX 75503	10/7/2024 4:10 PM
Addresses	Billing Address	Insert	Hospital Type Change Request		CHRISTUS ST MICHAEL 2600 ST MICHAEL DRIVE TEXARKANA, TX 75503	10/7/2024 4:10 PM
Addresses	Shipping Address	Insert	Hospital Type Change Request		CHRISTUS St. Michael - Healthcare Center Pharmacy 2604 St. Michael Drive, Suite 200 Texarkana, TX 75503	10/7/2024 4:10 PM
Addresses	Shipping Address	Insert	Hospital Type Change Request		CHRISTUS ST MICHAEL 2600 ST MICHAEL DRIVE TEXARKANA, TX 75503	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		020976901	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		TX	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		020976902	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		TX	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		020976903	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		TX	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		094644402	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		TX	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		094353202	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		TX	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		1733229	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		LA	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		146008105	10/7/2024 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		AR	10/7/2024 4:10 PM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1295736734	10/7/2024 4:10 PM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		TX	10/7/2024 4:10 PM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1467591396	10/7/2024 4:10 PM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		TX	10/7/2024 4:10 PM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1689702334	10/7/2024 4:10 PM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		TX	10/7/2024 4:10 PM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1295736734	10/7/2024 4:10 PM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		LA	10/7/2024 4:10 PM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1467591396	10/7/2024 4:10 PM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		LA	10/7/2024 4:10 PM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1689702334	10/7/2024 4:10 PM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		LA	10/7/2024 4:10 PM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1295736734	10/7/2024 4:10 PM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		AR	10/7/2024 4:10 PM
Contacts	Authorizing Official	Insert	Hospital Type Change Request		Adams, Jason President CHRISTUS St. Michael 9036142001	10/7/2024 4:10 PM
Contacts	Primary Contact	Insert	Hospital Type Change Request		Armstrong, Carly Coordinator Pharmacy 340B Program CHRISTUS St Michael 9036142929	10/7/2024 4:10 PM
Details	Assistance Received From Date	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Details	Assistance Received To Date	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Details	Last Recertification Date	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Details	Grant Number	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Details	340B ID	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Details	Is Authorizing Official EHB Data	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Details	Medicare Provider Number	Insert	Hospital Type Change Request		450801	10/7/2024 4:10 PM
Details	Entity Name	Insert	Hospital Type Change Request		CHRISTUS ST MICHAEL	10/7/2024 4:10 PM
Details	NOFO Number	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Details	Program Code	Insert	Hospital Type Change Request		RRC	10/7/2024 4:10 PM
Details	Entity Subname	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Dates	Participating Approval Date	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Details	State	Insert	Hospital Type Change Request		Pending	10/7/2024 4:10 PM
Dates	Registration Date	Insert	Hospital Type Change Request		10/7/2024 4:10:02 PM	10/7/2024 4:10 PM
Dates	Signed By Date	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Dates	Start Date	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Terminations	Termination Comments	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Terminations	Termination Date	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Terminations	Termination Effective Date	Insert	Hospital Type Change Request			10/7/2024 4:10 PM
Terminations	Termination Reason	Insert	Hospital Type Change Request			10/7/2024 4:10 PM