Covered Entity Details

DSH450388AS METHODIST HOSPITAL (Active) - information as of 4/23/2025 10:53:33 PM

Main Details

Name

METHODIST HOSPITAL

Subdivision Name

27905 Methodist FSER Nacogdoches - FSER Nacogdoches

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH450388AS

Medicare Provider Number

450388

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/10/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/28/2024

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

13434 Nacogdoches Rd
San Antonio, TX 78217

Billing Address

Methodist ER Nacogdoches
1151 Enterprise Drive
100
Coppell, TX 75019

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	094154402	1124074273

Shipping Addresses

Shipping Address 1

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

Shipping Address 2

Methodist ER Nacogdoches
13434 Nacogdoches Rd
San Antonio, TX 78217

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
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 Service Center 5919 W Campus Rd 120 San Antonio, TX 78247	Central Shared Services, LLC DBA San Antonio Supply Chain Service Center 5919 W Campus Drive 120 San Antonio, TX 78247	4/15/2025 6:58 AM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Bernal, Enrique DCFO Methodist Healthcare 2105750235	10/28/2024 8:06 AM
Details	340B ID	Update	New Registration		DSH450388AS	10/28/2024 8:06 AM
Details	Entity Subname	Update	New Registration	27905 Methodist FSER Nacogdoches	27905 Methodist FSER Nacogdoches - FSER Nacogdoches	10/28/2024 8:06 AM
Dates	Participating Approval Date	Update	New Registration		10/28/2024 8:06:52 AM	10/28/2024 8:06 AM
Details	State	Update	New Registration	Pending	Approved	10/28/2024 8:06 AM
Dates	Signed By Date	Update	New Registration		10/21/2024 2:33:08 PM	10/28/2024 8:06 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/28/2024 8:06 AM
Addresses	Main Address	Insert	New Registration		13434 Nacogdoches Rd San Antonio, TX 78217	10/10/2024 5:23 PM
Addresses	Billing Address	Insert	New Registration		Methodist ER Nacogdoches 1151 Enterprise Drive 100 Coppell, TX 75019	10/10/2024 5:23 PM
Addresses	Shipping Address	Insert	New Registration		Central Shared Services, LLC DBA San Antonio Supply Chain Service Center 5919 W Campus Rd 120 San Antonio, TX 78247	10/10/2024 5:23 PM
Addresses	Shipping Address	Insert	New Registration		Methodist ER Nacogdoches 13434 Nacogdoches Rd San Antonio, TX 78217	10/10/2024 5:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/10/2024 5:23 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		094154402	10/10/2024 5:23 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	10/10/2024 5:23 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124074273	10/10/2024 5:23 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	10/10/2024 5:23 PM
Contacts	Primary Contact	Insert	New Registration		Mandel, Jeffrey Brian VP of Pharmacy Services Methodist Healthcare 2109547525	10/10/2024 5:23 PM
Contacts	Authorizing Official	Insert	New Registration		Bernal, Enrique DCFO Methodist Healthcare 2105750235	10/10/2024 5:23 PM
Details	Assistance Received From Date	Insert	New Registration			10/10/2024 5:23 PM
Details	Assistance Received To Date	Insert	New Registration			10/10/2024 5:23 PM
Details	Last Recertification Date	Insert	New Registration			10/10/2024 5:23 PM
Details	Grant Number	Insert	New Registration			10/10/2024 5:23 PM
Details	340B ID	Insert	New Registration			10/10/2024 5:23 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/10/2024 5:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/10/2024 5:23 PM
Details	Medicare Provider Number	Insert	New Registration		450388	10/10/2024 5:23 PM
Details	Entity Name	Insert	New Registration		METHODIST HOSPITAL	10/10/2024 5:23 PM
Details	NOFO Number	Insert	New Registration			10/10/2024 5:23 PM
Details	Program Code	Insert	New Registration		DSH	10/10/2024 5:23 PM
Details	Entity Subname	Insert	New Registration		27905 Methodist FSER Nacogdoches	10/10/2024 5:23 PM
Dates	Participating Approval Date	Insert	New Registration			10/10/2024 5:23 PM
Details	State	Insert	New Registration		Pending	10/10/2024 5:23 PM
Dates	Registration Date	Insert	New Registration		10/10/2024 5:23:29 PM	10/10/2024 5:23 PM
Dates	Signed By Date	Insert	New Registration			10/10/2024 5:23 PM
Dates	Start Date	Insert	New Registration			10/10/2024 5:23 PM
Terminations	Termination Comments	Insert	New Registration			10/10/2024 5:23 PM
Terminations	Termination Date	Insert	New Registration			10/10/2024 5:23 PM
Terminations	Termination Effective Date	Insert	New Registration			10/10/2024 5:23 PM
Terminations	Termination Reason	Insert	New Registration			10/10/2024 5:23 PM