Covered Entity Details

PED453315-26 CHRISTUS Children's (Active) - information as of 4/25/2025 6:35:58 PM

Main Details

Name

CHRISTUS Children's

Subdivision Name

CHRISTUS CHILDREN'S - Stone Oak Genetics - Clinic

Type

Children's Hospital

Rural

340B ID

PED453315-26

Medicare Provider Number

453315

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/13/2025

Participating Start Date

4/1/2025

Participating Approval Date

1/27/2025

Last Recertification Date

Contacts

Authorizing Official

CHRISTUS Santa Rosa
Steve Chen, CFO
(210) 321-8031

Primary Contact

CHRISTUS Santa Rosa Health System
Dustyn Tysdal, REGIONAL DIRECTOR OF PHARMACY
(210) 704-0130

Addresses

Street Address

1434 E SONTERRA BLVD
STE 300
SAN ANTONIO, TX 78258-4974

Billing Address

CHRISTUS Children's
333 North Santa Rosa Street
San Antonio, TX 78207

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	020844904,020844905,020844903,020844902,020844906,091296603	1821004151

Shipping Addresses

Shipping Address 1

CHRISTUS Children's
333 North Santa Rosa Street
San Antonio, TX 78207

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
PED453315-01	Child	PED	Children's Hospital of San Antonio	Pediatric Multi-Specialty Center Westover Hills	11130 CHRISTUS Hills Medical Plaza 3, Suite 312D	San Antonio	TX	Terminated
PED453315-02	Child	PED	CHRISTUS Children's	Pediatric Multi-Specialty Center New Braunfels	598 N. Union Ave. STE 230	New Braunfels	TX	Active
PED453315-03	Child	PED	CHRISTUS Children's	Emergency Center	11130 CHRISTUS Hills, Suite 119	San Antonio	TX	Active
PED453315-04	Child	PED	CHRISTUS Children's	Specialty Care Center	15900 La Cantera Parkway	San Antonio	TX	Active
PED453315-05	Child	PED	CHRISTUS Children's	CHRISTUS Children's Emergency Center-Stone Oak - Free Standing Emergency Department	1434 Sonterra Blvd	San Antonio	TX	Active
PED453315-06	Child	PED	CHRISTUS Children's	Stone Oak Cardiology - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-07	Child	PED	CHRISTUS Children's	Stone Oak GI - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-08	Child	PED	CHRISTUS Children's	Stone Oak ED - MRI	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-09	Child	PED	CHRISTUS Children's	Stone Oak ENT - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-10	Child	PED	CHRISTUS Children's	Maternal Fetal Medicine Clinic - Clinic	315 N. San Saba	San Antonio	TX	Active
PED453315-11	Child	PED	CHRISTUS Children's	Stone Oak Orthopedics - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-12	Child	PED	CHRISTUS Children's	Alamo Ranch Clinic - Clinic	11345 Alamo Ranch Pkwy.	San Antonio	TX	Active
PED453315-13	Child	PED	CHRISTUS Children's	Stone Oak Nephrology - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-14	Child	PED	CHRISTUS Children's	Stone Oak Neurology - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-15	Child	PED	CHRISTUS Children's	Pedi Kidstop	11130 CHRISTUS HILLS	SAN ANTONIO	TX	Active
PED453315-16	Child	PED	CHRISTUS Children's	CHRISTUS Children's Multispecialty Clinic	5210 THOUSAND OAKS DR	SAN ANTONIO	TX	Active
PED453315-17	Child	PED	CHRISTUS Children's	CHRISTUS Children's Maternal Fetal Medicine - New Braunfels - Clinic	2115 STEPHENS PL	NEW BRAUNFELS	TX	Active
PED453315-18	Child	PED	CHRISTUS Children's	Stone Oak Respiratory Therapy - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-19	Child	PED	CHRISTUS Children's	Stone Oak HemOnc - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-20	Child	PED	CHRISTUS Children's	Stone Oak General Surgery - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-21	Child	PED	CHRISTUS Children's	Stone Oak Clinic - Multi-Specialty	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-22	Child	PED	CHRISTUS Children's	CHRISTUS CHILDREN'S - CHILDREN'S HOSPITAL OF SAN ANTONIO SOUTHSIDE MULTISPECIALTY CLINIC	7430 BARLITE BLVD	SAN ANTONIO	TX	Active
PED453315-23	Child	PED	CHRISTUS Children's	CHRISTUS Children's - MATERNAL FETAL MEDICINE	11212 State Highway 151	San Antonio	TX	Active
PED453315-24	Child	PED	CHRISTUS Children's	CHRISTUS Children's Multispecialty Clinic - Genetics	5210 THOUSAND OAKS DR	SAN ANTONIO	TX	Active
PED453315-25	Child	PED	CHRISTUS Children's	CHRISTUS Children's Multispecialty Clinic - Neurology	5210 THOUSAND OAKS DR	SAN ANTONIO	TX	Active
PED453315-26	Child	PED	CHRISTUS Children's	CHRISTUS CHILDREN'S - Stone Oak Genetics - Clinic	1434 E SONTERRA BLVD	SAN ANTONIO	TX	Active
PED453315-27	Child	PED	CHRISTUS Children's	CHRISTUS CHILDREN'S - Stone Oak Pulmonology - Clinic	1434 E SONTERRA BLVD	SAN ANTONIO	TX	Active
PED453315-28	Child	PED	CHRISTUS Children's	CHRISTUS CENTER FOR WOMEN'S HEALTH - Women's Health	315 N SAN SABA	SAN ANTONIO	TX	Active
PED453315-29	Child	PED	CHRISTUS Children's	CHRISTUS CHILDREN'S - Specialty Care Center - Psychiatric Therapy	15900 LA CANTERA PKWY	SAN ANTONIO	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Chen, Steve CFO CHRISTUS Santa Rosa 2103218031	1/27/2025 9:12 AM
Details	340B ID	Update	New Registration		PED453315-26	1/27/2025 9:12 AM
Details	Entity Subname	Update	New Registration	CHRISTUS CHILDREN'S	CHRISTUS CHILDREN'S - Stone Oak Genetics - Clinic	1/27/2025 9:12 AM
Dates	Participating Approval Date	Update	New Registration		1/27/2025 9:12:35 AM	1/27/2025 9:12 AM
Details	State	Update	New Registration	Pending	Approved	1/27/2025 9:12 AM
Dates	Signed By Date	Update	New Registration		1/13/2025 4:41:27 PM	1/27/2025 9:12 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	1/27/2025 9:12 AM
Addresses	Main Address	Insert	New Registration		1434 E SONTERRA BLVD STE 300 SAN ANTONIO, TX 78258-4974	1/13/2025 4:41 PM
Addresses	Billing Address	Insert	New Registration		CHRISTUS Children's 333 North Santa Rosa Street San Antonio, TX 78207	1/13/2025 4:41 PM
Addresses	Shipping Address	Insert	New Registration		CHRISTUS Children's 333 North Santa Rosa Street San Antonio, TX 78207	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		020844904	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		020844905	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		020844903	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		020844902	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		020844906	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		091296603	1/13/2025 4:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	1/13/2025 4:41 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1821004151	1/13/2025 4:41 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	1/13/2025 4:41 PM
Contacts	Authorizing Official	Insert	New Registration		Chen, Steve CFO CHRISTUS Santa Rosa 2103218031	1/13/2025 4:41 PM
Contacts	Primary Contact	Insert	New Registration		Tysdal, Dustyn REGIONAL DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107040130	1/13/2025 4:41 PM
Details	Assistance Received From Date	Insert	New Registration			1/13/2025 4:41 PM
Details	Assistance Received To Date	Insert	New Registration			1/13/2025 4:41 PM
Details	Last Recertification Date	Insert	New Registration			1/13/2025 4:41 PM
Details	Grant Number	Insert	New Registration			1/13/2025 4:41 PM
Details	340B ID	Insert	New Registration			1/13/2025 4:41 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/13/2025 4:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/13/2025 4:41 PM
Details	Medicare Provider Number	Insert	New Registration		453315	1/13/2025 4:41 PM
Details	Entity Name	Insert	New Registration		CHRISTUS Children's	1/13/2025 4:41 PM
Details	NOFO Number	Insert	New Registration			1/13/2025 4:41 PM
Details	Program Code	Insert	New Registration		PED	1/13/2025 4:41 PM
Details	Entity Subname	Insert	New Registration		CHRISTUS CHILDREN'S	1/13/2025 4:41 PM
Dates	Participating Approval Date	Insert	New Registration			1/13/2025 4:41 PM
Details	State	Insert	New Registration		Pending	1/13/2025 4:41 PM
Dates	Registration Date	Insert	New Registration		1/13/2025 4:41:24 PM	1/13/2025 4:41 PM
Dates	Signed By Date	Insert	New Registration			1/13/2025 4:41 PM
Dates	Start Date	Insert	New Registration			1/13/2025 4:41 PM
Terminations	Termination Comments	Insert	New Registration			1/13/2025 4:41 PM
Terminations	Termination Date	Insert	New Registration			1/13/2025 4:41 PM
Terminations	Termination Effective Date	Insert	New Registration			1/13/2025 4:41 PM
Terminations	Termination Reason	Insert	New Registration			1/13/2025 4:41 PM