Covered Entity Details

DSH450237 SANTA ROSA HEALTHCARE (Active) - information as of 4/24/2025 11:10:36 PM

Main Details

Name

SANTA ROSA HEALTHCARE

Subdivision Name

CHRISTUS SANTA ROSA HOSPITAL MEDICAL CENTER

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450237

Medicare Provider Number

450237

Additional Details

Current Program Status

Active

Registration Date

4/13/2023

Participating Start Date

7/1/2023

Participating Approval Date

4/20/2023

Last Recertification Date

8/15/2024

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

2827 BABCOCK ROAD
SAN ANTONIO, TX 78229

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating from effective date: (07/1/2006) until terminated effective date: (01/1/2017), reinstatement effective date: (07/1/2023)	04/20/2023
1/30/12 UPDATED ENTITY NAME (WAS CHRISTUS SANTA ROSA HEALTHCARE); 6/4/2009- CORRECTED MEDICAID NUMBER (WAS LISTED AS 450237)	01/30/2012
6/4/2009- CORRECTED MEDICAID NUMBER (WAS LISTED AS 450237)	06/04/2009

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		1194787218

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
Contract Detail	15RX PHARMACY	11212 STATE HIGHWAY 151	MEDICAL PLAZA-2 SUITE 110	SAN ANTONIO	TX	78251	10/13/2023	01/01/2024			01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/20/2023	07/01/2023			07/01/2023
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/20/2023	07/01/2023			07/01/2023
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/20/2023	07/01/2023			07/01/2023
Contract Detail	ACCREDO HEALTH GROUP INC	9307 KIRBY DR		HOUSTON	TX	77054-2516	04/20/2023	07/01/2023			07/01/2023
Contract Detail	ACCREDO HEALTH GROUP INC	4343 W ROYAL LN STE 124		IRVING	TX	75063-2299	04/20/2023	07/01/2023			07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/20/2023	07/01/2023		07/01/2023	07/20/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/20/2023	07/01/2023			07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/20/2023	07/01/2023			07/01/2023
Contract Detail	AMERITA, INC.	6015 RANDOLPH BLVD		SAN ANTONIO	TX	78233-5719	04/20/2023	07/01/2023			07/01/2023
Contract Detail	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	07/13/2016	10/01/2016		01/01/2017	12/19/2016
Contract Detail	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	04/20/2023	07/01/2023			07/01/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	04/20/2023	07/01/2023			07/01/2023
Contract Detail	CHRISTUS SPECIALTY PHARMACY	MOTHER FRANCES REGIONAL HEALTH CARE CTR	800 E DAWSON ST STE 100	TYLER	TX	75701-2036	04/20/2023	07/01/2023	04/01/2025		03/12/2025
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01057	9140 GUILBEAU	SAN ANTONIO	TX	78250	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY # 4109	12835 POTRANCO RD	SAN ANTONIO	TX	78253	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07207	210 NORTH BUSINESS IH 35	NEW BRAUNFELS	TX	78130	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07341	9285 CULEBRA AVE	SAN ANTONIO	TX	78251	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07808	4805 MEDICAL DR	SAN ANTONIO	TX	78229	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07832	9838 POTRANCO RD	SAN ANTONIO	TX	78251	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 08990	12980 BANDERA RD	HELOTES	TX	78023	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY #10347	9686 MARBACH ROAD	SAN ANTONIO	TX	78245	04/20/2023	07/01/2023			07/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07808	4805 MEDICAL DR	SAN ANTONIO	TX	78229	01/10/2024	04/01/2024			04/01/2024
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/20/2023	07/01/2023		10/01/2023	10/23/2023
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/20/2023	07/01/2023		10/01/2023	10/23/2023
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/20/2023	07/01/2023		10/01/2023	10/23/2023
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/20/2023	07/01/2023		10/01/2023	10/23/2023
Contract Detail	GALAXY SPECIALTY PHARMACY	SUN PHARMA LLC	2829 BABCOCK RD STE 120	SAN ANTONIO	TX	78229	04/20/2023	07/01/2023			07/01/2023
Contract Detail	H-E-B Pharmacy #444	3323 SE Military Drive		San Antonion	TX	78223	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEALTHCARE CENTER PHARMACY	2604 ST MICHAEL DRIVE, SUITE 200		TEXARKANA	TX	75503	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #074	1655 HWY 46 WEST		NEW BRAUNFELS	TX	78132	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #085	10718 POTRANCO RD.		SAN ANTONIO	TX	78251	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #189	2130 CULEBRA RD		SAN ANTONIO	TX	78228	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #205	721 CASTROVILLE ROAD		SAN ANTONIO	TX	78237	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #235	9255 FM 471 WEST		SAN ANTONIO	TX	78250	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #427	735 SW MILITARY DR		SAN ANTONIO	TX	78221	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #466	108 ROSILLO		SAN ANTONIO	TX	78207	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #494	10660 FM 471 WEST		SAN ANTONIO	TX	78251	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #556	2118 FREDERICKSBURG RD		SAN ANTONIO	TX	78201	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	HEB PHARMACY #678	302 VALLEY HI DR		SAN ANTONIO	TX	78227	01/30/2012	01/30/2012		01/01/2017	12/19/2016
Contract Detail	MOUNTAIN VALLEY PHARMACY		1395 SATTLER RD, STE 8 PO BOX 2229	CANYON LAKE	TX	78133-0009	02/09/2012	02/09/2012		01/01/2017	12/19/2016
Contract Detail	ONCO360		4041 HADLEY ROAD	SOUTH PLAINFIELD	NJ	07080	04/14/2015	07/01/2015		07/01/2015	12/19/2016
Contract Detail	ONCOMED PHARMACEUTICAL SERVICES OF MA, L	D/B/A ONCO360	335 BEAR HILL RD STE 2100	WALTHAM	MA	02451	04/14/2015	07/01/2015		07/01/2015	12/19/2016
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	04/14/2015	07/01/2015		07/01/2015	12/19/2016
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	04/20/2023	07/01/2023			07/01/2023
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF PHILADE	LLC DBA ONCO360	1553 CHESTER PIKE SUITE 206	CRUM LYNNE	PA	19022	04/14/2015	07/01/2015		07/01/2015	12/19/2016
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM INFUSION SERVICES 500, INC.	4620 S SAM HOUSTON PKWY W STE 440		HOUSTON	TX	77053	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUM PHARMACY 800, INC.	3016 GUADALUPE ST STE A		AUSTIN	TX	78705-2861	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/20/2023	07/01/2023		07/01/2024	08/07/2024
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/14/2015	07/01/2015		07/01/2015	12/19/2016
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/14/2015	07/01/2015		07/01/2015	12/19/2016
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/20/2023	07/01/2023			07/01/2023
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/20/2023	07/01/2023		08/17/2024	09/23/2024
Contract Detail	WAL-MART PHARMACY 10-0447	2410 DODSON STREET		DEL RIO	TX	78840	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	WAL-MART PHARMACY 10-0461	496 SOUTH BIBB STREET		EAGLE PASS	TX	78852	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	WAL-MART PHARMACY 10-0478	819 N. OAK ST		PEARSALL	TX	78061	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	WAL-MART PHARMACY 10-0865	1209 I H-35 SOUTH		NEW BRAUNFELS	TX	78130	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	WAL-MART PHARMACY 10-0865	1209 I H-35 SOUTH		NEW BRAUNFELS	TX	78130	04/20/2023	07/01/2023		09/01/2024	09/11/2024
Contract Detail	WAL-MART PHARMACY 10-2864	6703 E LESLIE ROAD		SAN ANTONIO	TX	78254	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	WAL-MART PHARMACY 10-3391	6102 FM 3009		SCHERTZ	TX	78154	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	WAL-MART PHARMACY 10-3888	11210 POTRANCO ROAD		SAN ANTONIO	TX	78253	01/25/2016	04/01/2016		01/01/2017	12/19/2016
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/20/2023	07/01/2023		08/17/2024	09/23/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00662	13430 SAN PEDRO AVE	SAN ANTONIO	TX	78216	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01194	8530 FM 78	CONVERSE	TX	78109	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02458	7802 WURZBACH ROAD	SAN ANTONIO	TX	78229	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02755	3065 RIGSBY AVE	SAN ANTONIO	TX	78222	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02943	2710 NOGALITOS	SAN ANTONIO	TX	78225	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02944	7423 BROADWAY ST	SAN ANTONIO	TX	78209	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15461	1560 BANDERA ROAD	SAN ANTONIO	TX	78228	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03083	10650 TOEPPERWEIN RD	CONVERSE	TX	78109	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03140	410 W. CYPRESS ST.	SAN ANTONIO	TX	78212	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03141	1105 GOLIAD ROAD	SAN ANTONIO	TX	78223	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03224	6901 SAN PEDRO AVE	SAN ANTONIO	TX	78216-6206	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03354	1106 CULEBRA	SAN ANTONIO	TX	78201	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03368	1581 AUSTIN HIGHWAY	SAN ANTONIO	TX	78218	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03504	6393 BABCOCK RD	SAN ANTONIO	TX	78240	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03505	6635 BANDERA RD	SAN ANTONIO	TX	78238	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03506	6363 RITTIMAN RD	SAN ANTONIO	TX	78218	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03562	9080 MARBACH ROAD	SAN ANTONIO	TX	78245	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03563	7103 MARBACH ROAD	SAN ANTONIO	TX	78227	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03571	14505 NW MILITARY HWY	SHAVANO PARK	TX	78231	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03634	3326 FREDERICKSBURG ROAD	SAN ANTONIO	TX	78201	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03734	8202 CULEBRA RD	SAN ANTONIO	TX	78251	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03804	7655 TEZEL RD	SAN ANTONIO	TX	78250	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03996	5760 WALZEM RD	WINDCREST	TX	78218	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04160	2200 E. HOUSTON ST	SAN ANTONIO	TX	78202	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04274	2425 THOUSAND OAKS DRIVE	SAN ANTONIO	TX	78232	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04374	10411 WEST AVENUE	SAN ANTONIO	TX	78213	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04551	11707 HUEBNER ROAD	SAN ANTONIO	TX	78230	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04552	4703 W. COMMERCE ST.	SAN ANTONIO	TX	78237	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04838	19203 STONE OAK PKWY	SAN ANTONIO	TX	78258	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04934	6017 INGRAM ROAD	SAN ANTONIO	TX	78238	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05424	138 SW MILITARY DRIVE	SAN ANTONIO	TX	78221	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05765	1223 S MAIN ST	BOERNE	TX	78006	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05963	3801 FM 3009	SCHERTZ	TX	78154	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05964	3401 SAN PEDRO	SAN ANTONIO	TX	78212	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06335	14025 NACOGDOCHES RD	SAN ANTONIO	TX	78247-1918	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06336	10718 BANDERA ROAD	SAN ANTONIO	TX	78250	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06337	1160 S BUSINESS IH 35	NEW BRAUNFELS	TX	78130	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06537	14882 BLANCO ROAD	SAN ANTONIO	TX	78216	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07214	20800 US 281 NORTH	SAN ANTONIO	TX	78258	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07308	4351 THOUSAND OAKS DRIVE	SAN ANTONIO	TX	78217-2101	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07371	7019 S ZARZAMORA ST	SAN ANTONIO	TX	78224-1141	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07571	10673 CULEBRA RD	SAN ANTONIO	TX	78251-1346	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07922	11658 IH 35 NORTH	SAN ANTONIO	TX	78233-5305	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07923	22114 BULVERDE ROAD	SAN ANTONIO	TX	78259	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07939	9903 POTRANCO RD	SAN ANTONIO	TX	78251	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09180	11103 W MILITARY DR	SAN ANTONIO	TX	78251	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09394	1210 N IH35 BUSINESS LOOP	NEW BRAUNFELS	TX	78130	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09615	3030 GOLIAD RD	SAN ANTONIO	TX	78223-3959	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09697	10003 W LOOP 1604 N	SAN ANTONIO	TX	78254	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09810	1357 EAST COURT STREET	SEGUIN	TX	78155-5130	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10393	1610 STATE HWY 46 WEST	NEW BRAUNFELS	TX	78132-4737	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11276	502 NEW VALLEY HI	SAN ANTONIO	TX	78227	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11520	13619 BABCOCK RD.	SAN ANTONIO	TX	78249	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11521	10858 WURZBACH RD.	SAN ANTONIO	TX	78230-2434	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11725	2070 W. OAKLAWN RD.	PLEASANTON	TX	78064	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11928	5960 FM 1103	NEW BRAUNFELS	TX	78132	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11971	20226 STONE OAK PKWY.	SAN ANTONIO	TX	78258	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12479	121 N. ZARZAMORA ST.	SAN ANTONIO	TX	78207-3739	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12519	1902 N LOOP 1604 W	SAN ANTONIO	TX	78248	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12520	300 E. HOUSTON ST.	SAN ANTONIO	TX	78205-1816	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13086	1944 S. SEGUIN AVE.	NEW BRAUNFELS	TX	78130	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02458	7802 WURZBACH ROAD	SAN ANTONIO	TX	78229	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03140	410 W. CYPRESS ST.	SAN ANTONIO	TX	78212	04/20/2023	07/01/2023		07/03/2024	07/23/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03634	3326 FREDERICKSBURG ROAD	SAN ANTONIO	TX	78201	04/20/2023	07/01/2023		07/03/2024	07/23/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04552	4703 W. COMMERCE ST.	SAN ANTONIO	TX	78237	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06337	1160 S BUSINESS IH 35	NEW BRAUNFELS	TX	78130	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07939	9903 POTRANCO RD	SAN ANTONIO	TX	78251	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09180	11103 W MILITARY DR	SAN ANTONIO	TX	78251	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12716	12020 CULEBRA RD	SAN ANTONIO	TX	78253	04/20/2023	07/01/2023			07/01/2023
Contract Detail	Walgreens #21373	Walgreens Central Fill #21373	4100 Dale Earnhardt Way STE 200	Northlake	TX	76262	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/11/2013	10/01/2013		01/01/2017	12/19/2016
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	04/20/2023	07/01/2023			07/01/2023
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/20/2023	07/01/2023		08/17/2024	09/23/2024
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/16/2023	01/01/2024		08/17/2024	09/23/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH450237AA	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Pedi OP Day Surgery	11212 State Highway 151	San Antonio	TX	Active
DSH450237AL	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Emergency Room	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AM	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - LDRP	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AN	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Cardiac Cath	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AP	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Day Surgery	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AQ	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital New Braunfels - Hyper Oxyg Ther	600 North Union Avenue	New Braunfels	TX	Terminated
DSH450237AR	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital New Braunfels - Wound Care	600 North Union Avenue	New Braunfels	TX	Terminated
DSH450237AS	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - O/P Chemotherap	Medical Plaza Building, 598 North Union Avenue, 1st Floor	New Braunfels	TX	ToBeTerminated
DSH450237AT	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Outpatient Radiology 1	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AU	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	MC Wound Care Center Downtown	315 N. San Saba	San Antonio	TX	Terminated
DSH450237AV	Child	DSH	SANTA ROSA HEALTHCARE	Creekside Crossing ED	244 Creekside Crossing	New Braunfels	TX	ToBeTerminated
DSH450237AW	Child	DSH	SANTA ROSA HEALTHCARE	Alon Emergency Center	11503 Northwest Military Highway	San Antonio	TX	Active
DSH450237AX	Child	DSH	SANTA ROSA HEALTHCARE	Creekside Crossing OP Imaging - Radiology	244 Creekside Crossing	New Braunfels	TX	ToBeTerminated
DSH450237AZ	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HOSPITAL-WESTOV / LDRP	11212 STATE HWY 151 BLDG 3	SAN ANTONIO	TX	Terminated
DSH450237BA	Child	DSH	SANTA ROSA HEALTHCARE	Med Surg Observation Beds / Med Surg D	600 N UNION AVE	NEW BRAUNFELS	TX	ToBeTerminated
DSH450237BB	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HOSPITAL Observation Beds / Intermd Cre-Gen	600 N UNION AVE	NEW BRAUNFELS	TX	Terminated
DSH450237BC	Child	DSH	SANTA ROSA HEALTHCARE	RAS Hematology - Laboratory	403 Treeline Park	San Antonio	TX	Active
DSH450237BD	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Spine Center	2833 BABCOCK RD	San Antonio	TX	Active
DSH450237BE	Child	DSH	SANTA ROSA HEALTHCARE	RAS Central Service - Supply	403 Treeline Park	San Antonio	TX	Active
DSH450237BF	Child	DSH	SANTA ROSA HEALTHCARE	RAS ENDOSCOPY - Endoscopy - Endoscopy	403 Treeline Park	San Antonio	TX	Terminated
DSH450237BG	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Cardiothoracic Center - New Braunfels	730 N HOUSTON AVE	New Braunfels	TX	ToBeTerminated
DSH450237BH	Child	DSH	SANTA ROSA HEALTHCARE	ECC OB ED Unit at Santa Rosa Hospital Westover Hills	11212 State Highway 151	SAN ANTONIO	TX	Active
DSH450237BJ	Child	DSH	SANTA ROSA HEALTHCARE	RAS EKG - Cardiology	403 Treeline Park	San Antonio	TX	Active
DSH450237BK	Child	DSH	SANTA ROSA HEALTHCARE	RAS LAB - GENERAL 1 - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237BL	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Hyper Oxygen Therapy	11212 State Highway 151	San Antonio	TX	Active
DSH450237BM	Child	DSH	SANTA ROSA HEALTHCARE	RAS SURGERY-GENERAL - Surgery	403 Treeline Park	San Antonio	TX	Active
DSH450237BN	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Surgical Solutions - Bariatrics	11212 STATE HIGHWAY 151, BLDG 2	San Antonio,	TX	Active
DSH450237BP	Child	DSH	SANTA ROSA HEALTHCARE	RAS MICROBIOLOGY - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237BQ	Child	DSH	SANTA ROSA HEALTHCARE	RAS Cat Scanner - Imaging - Cat Scanner	403 Treeline Park	San Antonio	TX	Active
DSH450237BR	Child	DSH	SANTA ROSA HEALTHCARE	RAS PHYS THERAPY - Physical Therapy	403 Treeline Park	San Antonio	TX	Active
DSH450237BS	Child	DSH	SANTA ROSA HEALTHCARE	RAS Anesthesiology - Anesthesiology	403 Treeline Park	San Antonio	TX	Active
DSH450237BT	Child	DSH	SANTA ROSA HEALTHCARE	RAS Blood Bank - Transfusion	403 Treeline Park	San Antonio	TX	Active
DSH450237BU	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - MRI	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237BV	Child	DSH	SANTA ROSA HEALTHCARE	RAS Chemistry - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237BW	Child	DSH	SANTA ROSA HEALTHCARE	RAS RESPIR THERAPY - Respiration Therapy	403 Treeline Park	San Antonio	TX	Active
DSH450237BX	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Day Surgery - Operating Room	11212 State Highway 151	San Antonio	TX	Active
DSH450237BY	Child	DSH	SANTA ROSA HEALTHCARE	RAS REFERENCE LAB 1 - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237BZ	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - CT Scan	600 N. Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237CA	Child	DSH	SANTA ROSA HEALTHCARE	RAS ULTRASOUND - Imaging - Ultrasound	403 Treeline Park	San Antonio	TX	Active
DSH450237CB	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HOSPITAL Outpatient Observation Beds / Intermd Cre-Gen - Adults & Pediatrics	600 N UNION AVE	NEW BRAUNFELS	TX	ToBeTerminated
DSH450237CC	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - Laboratory	600 N. Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237CD	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Orthopedic & Sports Medicine Clinic	2833 BABCOCK ROAD	San Antonio	TX	Active
DSH450237CE	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA NEUROSURGICAL SPINE - MEDICAL CENTER - NEUROSURGICAL SPINE - NEUROSURGICAL SPINE	423 TREELINE PARK	San Antonio	TX	Terminated
DSH450237CF	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - Radiology Diagnostic	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237CG	Child	DSH	SANTA ROSA HEALTHCARE	RAS RECOVERY ROOM - Recovery	403 Treeline Park	San Antonio	TX	Active
DSH450237CH	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Neurosurgical Spine - Medical Center	2829 Babcock Rd	San Antonio	TX	Active
DSH450237CJ	Child	DSH	SANTA ROSA HEALTHCARE	RAS SEROLOGY - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237CK	Child	DSH	SANTA ROSA HEALTHCARE	RAS HIST-CYT-PATH - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237CL	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Orthopedic & Sports Medicine Clinic- WH	11212 STATE HIGHWAY 151	San Antonio	TX	Active
DSH450237CM	Child	DSH	SANTA ROSA HEALTHCARE	RAS URINANALYSIS - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237CN	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - Radiology - Therapeutic	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237CP	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Orthopedic and Sports Medicine	423 Treeline Park	San Antonio	TX	Active
DSH450237CQ	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Urology Clinic	2833 BABCOCK RD	SAN ANTONIO	TX	Active
DSH450237CR	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HEART & VASCULA - Heart and Vascular Clinic	479 OXFORD DR	NEW BRAUNFELS	TX	ToBeTerminated
DSH450237CS	Child	DSH	SANTA ROSA HEALTHCARE	NEW BRAUNFELS - NEUROSURGICAL SPINE	11212 STATE HIGHWAY 151	SAN ANTONIO	TX	Active
DSH450237D	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services	Medical Plaza Building	New Braunfels	TX	Terminated
DSH450237E	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Imaging Center - Alamo Heights	423 Treeline Park	San Antonio	TX	Terminated
DSH450237F	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Pulmonary Rehab	750 Landa Street	New Braunfels	TX	Terminated
DSH450237G	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Cardiac Rehab	750 Landa Street	New Braunfels	TX	Terminated
DSH450237H	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Physical Therapy	750 Landa Street	New Braunfels	TX	Terminated
DSH450237J	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Speech Therapy	750 Landa Street	New Braunfels	TX	Terminated
DSH450237K	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Occupational Therapy	750 Landa Street	New Braunfels	TX	Terminated
DSH450237L	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital New Braunfels - Wound Care	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	Terminated
DSH450237M	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Wound Care	2833 Babcock Road, Suite 105	San Antonio	TX	Terminated
DSH450237N	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hyperbaric Center	2833 Babcock Road, Suite 105	San Antonio	TX	Active
DSH450237P	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Hyperbaric Center	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237Q	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Health System Rehabilitation Center for Adults and Children	2701 Babcock Road	San Antonio	TX	Terminated
DSH450237T	Child	DSH	SANTA ROSA HEALTHCARE	Alamo Heights - Radiology - Diagnostic	403 Treeline Park	San Antonio	TX	Active
DSH450237U	Child	DSH	SANTA ROSA HEALTHCARE	Alamo Heights - Emergency Room	403 Treeline Park	San Antonio	TX	Active
DSH450237V	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Emergency Room	11212 State Highway 151	San Antonio	TX	Active
DSH450237W	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Endoscopy/G.I.	11212 State Highway 151	San Antonio	TX	Active
DSH450237X	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Cardiac Cath	11212 State Highway 151	San Antonio	TX	Active
DSH450237Y	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital Westover Hills - Day Surgery	11212 State Highway 151	San Antonio	TX	Terminated
DSH450237Z	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital Westover Hills - Med/Surg D	11212 State Highway 151	San Antonio	TX	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 11:29:26 AM	8/15/2024 3:02:33 PM	8/15/2024 3:02 PM
Contacts	Primary Contact	Update	PC Change Request	Aniemeke, Emmanuel Director of Pharmacy Services CHRISTUS Hospital Santa Rosa Medical Center 2107056193	Tysdal, Dustyn REGIONAL DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107040130	6/12/2024 1:08 PM
Details	Last Recertification Date	Update	Recertification		8/15/2023 11:29:26 AM	8/15/2023 11:29 AM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0208449-08; 0208449-09; 1194787218 (TX)		4/28/2023 3:56 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0208449-09; 0208449-08; 1194787218 (TX)		4/28/2023 3:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/27/2023 3:07 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0208449-09; 0208449-08; 1194787218	4/27/2023 3:07 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		TX	4/27/2023 3:07 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0944860-01 (TX)		4/27/2023 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/27/2023 3:01 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0208449-08; 0208449-09; 1194787218	4/27/2023 3:01 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		TX	4/27/2023 3:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0208449-01 (TX)		4/27/2023 3:01 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0944860-02 (TX)		4/27/2023 3:01 PM
Addresses	Shipping Address	Delete	Hospital Type Change Request	CHRISTUS Santa Rosa Health System 2827 Babcock Road San Antonio, TX 78229		4/20/2023 8:20 AM
Addresses	Shipping Address	Delete	Hospital Type Change Request	HEB Grocery Company, LP HEB Pharmacy Warehouse 6520 Fratt Rd. San Antonio, TX 78218		4/20/2023 8:20 AM
Medicaid Billing	NPI: State	Update	Hospital Type Change Request		TX	4/20/2023 8:20 AM
Contacts	Authorizing Official	Update	Hospital Type Change Request	Kirks, Linda Regional VP/CFO The Children's Hospital of San Antonio 2107042624	Chen, Steve CFO CHRISTUS Santa Rosa 2103218031	4/20/2023 8:20 AM
Contacts	Signed By	Insert	Hospital Type Change Request		Chen, Steve CFO CHRISTUS Santa Rosa 2103218031	4/20/2023 8:20 AM
Contacts	Primary Contact	Update	Hospital Type Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107042935	Aniemeke, Emmanuel Director of Pharmacy Services CHRISTUS Hospital Santa Rosa Medical Center 2107056193	4/20/2023 8:20 AM
Details	Last Recertification Date	Update	Hospital Type Change Request	8/31/2016 12:00:00 AM		4/20/2023 8:20 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request	11/28/2016 12:00:00 AM		4/20/2023 8:20 AM
Details	Entity Name	Update	Hospital Type Change Request	CHRISTUS SANTA ROSA HEALTH SYSTEM	SANTA ROSA HEALTHCARE	4/20/2023 8:20 AM
Dates	Participating Approval Date	Update	Hospital Type Change Request	6/12/2006 12:00:00 AM	4/20/2023 8:20:19 AM	4/20/2023 8:20 AM
Details	State	Update	Hospital Type Change Request	Terminated	Approved	4/20/2023 8:20 AM
Dates	Registration Date	Update	Hospital Type Change Request	5/31/2006 12:00:00 AM	4/13/2023 12:22:30 PM	4/20/2023 8:20 AM
Dates	Signed By Date	Update	Hospital Type Change Request	5/15/2006 12:00:00 AM	4/13/2023 12:22:40 PM	4/20/2023 8:20 AM
Dates	Start Date	Update	Hospital Type Change Request	7/1/2006 12:00:00 AM	7/1/2023 12:00:00 AM	4/20/2023 8:20 AM
Terminations	Termination Date	Update	Hospital Type Change Request	1/1/2017 12:00:00 AM		4/20/2023 8:20 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request	11/30/2016 12:00:00 AM		4/20/2023 8:20 AM
Terminations	Termination Reason	Update	Hospital Type Change Request	DSH percentage below statutory minimum		4/20/2023 8:20 AM
Details	Comments Public	Insert	Hospital Type Change Request		Participating from effective date: (07/1/2006) until terminated effective date: (01/1/2017), reinstatement effective date: (07/1/2023)	4/20/2023 7:55 AM
Contacts	Primary Contact	Update	Group Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS ST MICHAEL HEALTH SYTEM 9036142928	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107042935	10/25/2021 11:27 AM
Contacts	Primary Contact	Update	Profile Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Hospital - New Braunfels 8306435377	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS ST MICHAEL HEALTH SYTEM 9036142928	2/20/2020 1:19 PM
Contacts	Primary Contact	Update	Hospital Type Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY 8306435377	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Hospital - New Braunfels 8306435377	4/16/2018 9:23 AM
Contacts	Authorizing Official	Update		Kirks, Linda Regional VP/CFO 2107042624	Kirks, Linda Regional VP/CFO The Children's Hospital of San Antonio 2107042624	10/9/2017 3:50 PM
Contacts	Authorizing Official	Update		Marquart, Tricia Interim Regional Chief Financial Officer 2107048773	Kirks, Linda Regional VP/CFO 2107042624	7/25/2017 10:25 AM
Addresses	Main Address	Insert			2827 BABCOCK ROAD SAN ANTONIO, TX 78229	12/19/2016 8:17 AM
Addresses	Shipping Address	Insert			CHRISTUS Santa Rosa Health System 2827 Babcock Road San Antonio, TX 78229	12/19/2016 8:17 AM
Addresses	Shipping Address	Insert			HEB Grocery Company, LP HEB Pharmacy Warehouse 6520 Fratt Rd. San Antonio, TX 78218	12/19/2016 8:17 AM
Contacts	Primary Contact	Update		NIEMIEC, GREGG DIRECTOR OF PHARMACY 2107042935	Tysdal, Dustyn DIRECTOR OF PHARMACY 8306435377	12/19/2016 8:17 AM
Dates	Last Date That 340B Drugs Purchased	Update			11/28/2016 12:00:00 AM	12/19/2016 8:17 AM
Details	State	Update		Active	Terminated	12/19/2016 8:17 AM
Terminations	Termination Date	Update			1/1/2017 12:00:00 AM	12/19/2016 8:17 AM
Terminations	Termination Effective Date	Update			11/30/2016 12:00:00 AM	12/19/2016 8:17 AM
Terminations	Termination Reason	Update			DSH percentage below statutory minimum	12/19/2016 8:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/31/2016 12:25 PM
Medicaid Billing	Medicaid: Number	Insert			0944860-02	8/31/2016 12:25 PM
Medicaid Billing	Medicaid: State	Insert			TX	8/31/2016 12:25 PM
Details	Last Recertification Date	Update		8/19/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 12:25 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/20/2015 6:07 PM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	8/19/2015 12:00:00 AM	8/20/2015 6:07 PM
Contacts	Authorizing Official	Insert			Marquart, Tricia Interim Regional Chief Financial Officer 2107048773	11/14/2014 2:16 PM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 8:47 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/12/2013 12:00:00 AM	9/12/2013 3:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/12/2013 6:25 AM
Medicaid Billing	Medicaid: Number	Insert			0944860-01	8/12/2013 6:25 AM
Medicaid Billing	Medicaid: State	Insert			TX	8/12/2013 6:25 AM
Medicaid Billing	NPI: Number	Insert			1194787218	8/12/2013 6:25 AM
Details	Entity Subname	Update			CHRISTUS SANTA ROSA HOSPITAL MEDICAL CENTER	4/9/2013 12:39 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/29/2012 1:09 PM
Contacts	Primary Contact	Insert			NIEMIEC, GREGG DIRECTOR OF PHARMACY 2107042935	1/30/2012 12:49 PM
Details	Entity Name	Update		CHRISTUS SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HEALTH SYSTEM	1/30/2012 12:49 PM
Details	Comments Public	Insert			1/30/12 UPDATED ENTITY NAME (WAS CHRISTUS SANTA ROSA HEALTHCARE); 6/4/2009- CORRECTED MEDICAID NUMBER (WAS LISTED AS 450237)	1/30/2012 12:49 PM
Details	Last Recertification Date	Insert				6/4/2009 5:23 PM
Details	Grant Number	Insert				6/4/2009 5:23 PM
Details	340B ID	Insert			DSH450237	6/4/2009 5:23 PM
Details	Is Authorizing Official EHB Data	Insert				6/4/2009 5:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert				6/4/2009 5:23 PM
Details	Medicare Provider Number	Insert			450237	6/4/2009 5:23 PM
Details	Entity Name	Insert			CHRISTUS SANTA ROSA HEALTHCARE	6/4/2009 5:23 PM
Details	Program Code	Insert			DSH	6/4/2009 5:23 PM
Details	Entity Subname	Insert				6/4/2009 5:23 PM
Dates	Participating Approval Date	Insert			6/12/2006 12:00:00 AM	6/4/2009 5:23 PM
Details	State	Insert			Active	6/4/2009 5:23 PM
Dates	Registration Date	Insert			5/31/2006 12:00:00 AM	6/4/2009 5:23 PM
Dates	Signed By Date	Insert			5/15/2006 12:00:00 AM	6/4/2009 5:23 PM
Dates	Start Date	Insert			7/1/2006 12:00:00 AM	6/4/2009 5:23 PM
Terminations	Termination Comments	Insert				6/4/2009 5:23 PM
Terminations	Termination Date	Insert				6/4/2009 5:23 PM
Terminations	Termination Effective Date	Insert				6/4/2009 5:23 PM
Terminations	Termination Reason	Insert				6/4/2009 5:23 PM
Details	Comments Public	Insert			6/4/2009- CORRECTED MEDICAID NUMBER (WAS LISTED AS 450237)	6/4/2009 5:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	5/31/2006 12:04 PM
Medicaid Billing	Medicaid: Number	Insert			0208449-01	5/31/2006 12:04 PM
Medicaid Billing	Medicaid: State	Insert			TX	5/31/2006 12:04 PM