Covered Entity Details

DSH190004K THIBODAUX REGIONAL HEALTH SYSTEM (Approved) - information as of 6/8/2025 11:56:13 PM

Main Details

Name

THIBODAUX REGIONAL HEALTH SYSTEM

Subdivision Name

THIBODAUX REGIONAL WOUND CARE & LIM - Wound Care and Limb Preservation

Type

Disproportionate Share Hospital

Rural

340B ID

DSH190004K

Medicare Provider Number

190004

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/11/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/22/2025

Last Recertification Date

Contacts

Authorizing Official

Thibodaux Regional Health System
Morgan B Waguespack, Controller
(985) 493-4530

Primary Contact

Thibodaux Regional Health System
April Benoit Denning, Director of Pharmacy
(985) 493-4545

Addresses

Street Address

290 BOWIE RD
STE A
THIBODAUX, LA 70301-6712

Billing Address
Same as Street Address

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
LA	1736848	1902465065

Shipping Addresses

Same as Street Address

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
DSH190004A	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	IMAGING & DIAGNOSTIC CENTER OF THIB - CT Scan - WC	726 N ACADIA RD	THIBODAUX	LA	Active
DSH190004B	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	Thibodaux Regional Cancer Institute - Radiation	608 N ACADIA RD	THIBODAUX	LA	Active
DSH190004C	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	IMAGING & DIAGNOSTIC CENTER OF THIB - MRI - WC	726 N ACADIA RD	THIBODAUX	LA	Active
DSH190004D	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	IMAGING & DIAGNOSTIC CENTER OF THIB - Diagnostic Radiology -WC	726 N ACADIA RD	THIBODAUX	LA	Active
DSH190004E	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	IMAGING & DIAGNOSTIC CENTER OF THIB - Ultrasound -WC	726 N ACADIA RD	THIBODAUX	LA	Active
DSH190004F	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	Thibodaux Regional Cancer Institute - Infusion	608 N ACADIA RD	THIBODAUX	LA	Active
DSH190004G	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	IMAGING & DIAGNOSTIC CENTER OF THIB - Bone Density - WC	726 N ACADIA RD	THIBODAUX	LA	Active
DSH190004H	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	Lady of the Sea Specialty Clinic - Oncology	195 West 134th St.	Cut Off	LA	Terminated
DSH190004J	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	Thibodaux Regional Cancer Institute-Physician Clinics - Physician Clinics	608 N ACADIA RD	THIBODAUX	LA	Active
DSH190004K	Child	DSH	THIBODAUX REGIONAL HEALTH SYSTEM	THIBODAUX REGIONAL WOUND CARE & LIM - Wound Care and Limb Preservation	290 BOWIE RD	THIBODAUX	LA	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Waguespack, Morgan B Controller Thibodaux Regional Health System 9854934530	5/22/2025 11:57 AM
Details	340B ID	Update	New Registration		DSH190004K	5/22/2025 11:57 AM
Details	Entity Subname	Update	New Registration	THIBODAUX REGIONAL WOUND CARE & LIM	THIBODAUX REGIONAL WOUND CARE & LIM - Wound Care and Limb Preservation	5/22/2025 11:57 AM
Dates	Participating Approval Date	Update	New Registration		5/22/2025 11:57:08 AM	5/22/2025 11:57 AM
Details	State	Update	New Registration	Pending	Approved	5/22/2025 11:57 AM
Dates	Signed By Date	Update	New Registration		5/14/2025 5:41:00 PM	5/22/2025 11:57 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/22/2025 11:57 AM
Contacts	Authorizing Official	Update	Change Request	East, Stephen H Chief Financial Officer Thibodaux Regional Health System 9854934740-4774	Waguespack, Morgan B Controller Thibodaux Regional Health System 9854934530	5/14/2025 3:14 PM
Contacts	Authorizing Official	Update	Profile Change Request	East, Stephen H Chief Financial Officer Thibodaux Regional Health System 9854934740	East, Stephen H Chief Financial Officer Thibodaux Regional Health System 9854934740-4774	4/30/2025 7:57 AM
Contacts	Primary Contact	Update	Profile Change Request	Denning, April Benoit Director of Pharmacy Thibodaux Regional Medical Center 9854934545	Denning, April Benoit Director of Pharmacy Thibodaux Regional Health System 9854934545	4/30/2025 6:33 AM
Contacts	Authorizing Official	Update	Profile Change Request	East, Stephen H Chief Financial Officer Thibodaux Regional Health System 9854465033-4740	East, Stephen H Chief Financial Officer Thibodaux Regional Health System 9854934740	4/29/2025 4:52 PM
Addresses	Main Address	Insert	New Registration		290 BOWIE RD STE A THIBODAUX, LA 70301-6712	4/11/2025 10:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 10:36 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1736848	4/11/2025 10:36 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/11/2025 10:36 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1902465065	4/11/2025 10:36 AM
Medicaid Billing	NPI: State	Insert	New Registration		LA	4/11/2025 10:36 AM
Contacts	Primary Contact	Insert	New Registration		Denning, April Benoit Director of Pharmacy Thibodaux Regional Medical Center 9854934545	4/11/2025 10:36 AM
Contacts	Authorizing Official	Insert	New Registration		East, Stephen H Chief Financial Officer Thibodaux Regional Health System 9854465033-4740	4/11/2025 10:36 AM
Details	Assistance Received From Date	Insert	New Registration			4/11/2025 10:36 AM
Details	Assistance Received To Date	Insert	New Registration			4/11/2025 10:36 AM
Details	Last Recertification Date	Insert	New Registration			4/11/2025 10:36 AM
Details	Grant Number	Insert	New Registration			4/11/2025 10:36 AM
Details	340B ID	Insert	New Registration			4/11/2025 10:36 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2025 10:36 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2025 10:36 AM
Details	Medicare Provider Number	Insert	New Registration		190004	4/11/2025 10:36 AM
Details	Entity Name	Insert	New Registration		THIBODAUX REGIONAL HEALTH SYSTEM	4/11/2025 10:36 AM
Details	NOFO Number	Insert	New Registration			4/11/2025 10:36 AM
Details	Program Code	Insert	New Registration		DSH	4/11/2025 10:36 AM
Details	Entity Subname	Insert	New Registration		THIBODAUX REGIONAL WOUND CARE & LIM	4/11/2025 10:36 AM
Dates	Participating Approval Date	Insert	New Registration			4/11/2025 10:36 AM
Details	State	Insert	New Registration		Pending	4/11/2025 10:36 AM
Dates	Registration Date	Insert	New Registration		4/11/2025 10:36:57 AM	4/11/2025 10:36 AM
Dates	Signed By Date	Insert	New Registration			4/11/2025 10:36 AM
Dates	Start Date	Insert	New Registration			4/11/2025 10:36 AM
Terminations	Termination Comments	Insert	New Registration			4/11/2025 10:36 AM
Terminations	Termination Date	Insert	New Registration			4/11/2025 10:36 AM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2025 10:36 AM
Terminations	Termination Reason	Insert	New Registration			4/11/2025 10:36 AM