Covered Entity Details

DSH450686 UNIVERSITY MEDICAL CENTER (Active) - information as of 4/25/2025 6:33:56 PM

Main Details

Name

UNIVERSITY MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450686

Medicare Provider Number

450686

Additional Details

Current Program Status

Active

Registration Date

10/16/2007

Participating Start Date

12/1/1992

Participating Approval Date

10/16/2007

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

University Medical Center
John Lowe, Vice President of Support Services
(806) 775-8516

Primary Contact

University Medical Center
Courtney Armstrong, Director of Pharmacy
(806) 775-9391

Addresses

Street Address

602 INDIANA AVE
LUBBOCK, TX 79415

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
TX	137999206,250296	1821087164,1619561537,1679521652,1861175564,1831820893,1417729708
NM	A9745	1821087164,1619561537,1679521652,1417729708,1831820893,1861175564

Shipping Addresses

Shipping Address 1

UNIVERSITY MEDICAL CENTER
602 INDIANA AVE
LUBBOCK, TX 79415

Shipping Address 2

UMC OUTPATIENT CENTER PHARMACY
7105 KEWANEE AVE
LUBBOCK, TX 79424

Shipping Address 3

UMC Pharmacy Health and Wellness
11011 Slide Road
Lubbock, TX 79424

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	AMARILLO PHARMACEUTICAL CARE CTR	TX TECH UNIVERSITY HSC	1400 S COULTER ST STE 1100	AMARILLO	TX	79106	07/13/2024	10/01/2024		10/01/2024
Contract Detail	AMIGOS PHARMACY #503	112 NORTH UNIVERSITY AVENUE		LUBBOCK	TX	79415	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	07/11/2014	10/01/2014	10/08/2018	12/13/2018
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01533	1801 WEST 5TH ST.	PLAINVIEW	TX	79072	04/14/2014	07/01/2014	11/22/2015	03/17/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07272	3402 SLIDE RD.	LUBBOCK	TX	79414	04/14/2014	07/01/2014	04/26/2016	04/26/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07277	3402 50TH ST.	LUBBOCK	TX	79413	04/14/2014	07/01/2014	04/26/2016	04/26/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 07811	5805 82ND ST	LUBBOCK	TX	79424	04/14/2014	07/01/2014	04/26/2016	04/26/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 08340	6420 19TH STREET	LUBBOCK	TX	79407	04/14/2014	07/01/2014	04/26/2016	04/26/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 08343	3801 19TH ST.	LUBBOCK	TX	79410	04/14/2014	07/01/2014	04/26/2016	04/26/2016
Contract Detail	MARKET STREET PHARMACY #502	3405 50TH STREET		LUBBOCK	TX	79413	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	MARKET STREET PHARMACY #543	4205 98TH STREET		LUBBOCK	TX	79423	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	MARKET STREET PHARMACY #553	4425 19TH STREET		LUBBOCK	TX	79407	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	UNITED PHARMACY #501	2630 PARKWAY DRIVE		LUBBOCK	TX	79403	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	UNITED PHARMACY #505	401 SLIDE ROAD		LUBBOCK	TX	79416	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	UNITED PHARMACY #506	1701 50TH STREET		LUBBOCK	TX	79412	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	UNITED PHARMACY #537	2703 82ND STREET		LUBBOCK	TX	79423	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	UNITED PHARMACY #551	8010 FRANKFORD		LUBBOCK	TX	79424	10/14/2014	01/01/2015	04/26/2016	04/26/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04819	5206 4TH STREET	LUBBOCK	TX	79416	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04820	1619 50TH STREET	LUBBOCK	TX	79412	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04821	3404 INDIANA AVENUE	LUBBOCK	TX	79413	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04822	4847 SLIDE ROAD	LUBBOCK	TX	79414	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05996	2417 82ND ST	LUBBOCK	TX	79423	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07853	5115 98TH STREET	LUBBOCK	TX	79424	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10283	6420 82ND STREET	LUBBOCK	TX	79424	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11233	602 AVENUE Q	LUBBOCK	TX	79401-2614	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15105	3009 SLIDE RD.	LUBBOCK	TX	79407	04/15/2014	07/01/2014	09/23/2016	09/23/2016
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/15/2014	07/01/2014	06/23/2015	06/23/2015

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH450686A	Child	DSH	UNIVERSITY MEDICAL CENTER	Lubbock County Hospital District - EMS	5505 Marsha Sharp Freeway	Lubbock	TX	Active
DSH450686B	Child	DSH	UNIVERSITY MEDICAL CENTER	Ambulatory Care Center	808 Joliet Avenue Suite 120	Lubbock	TX	Active
DSH450686C	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC OUTPATIENT GI CENTER - Gastroenterology	10202 QUAKER AVE	LUBBOCK	TX	Active
DSH450686D	Child	DSH	UNIVERSITY MEDICAL CENTER	URGENT CARE CENTER AT UMC - Urgent Care	808 JOLIET AVE	LUBBOCK	TX	Active
DSH450686E	Child	DSH	UNIVERSITY MEDICAL CENTER	Medication Therapy Management Center - Medication Therapy Management	7105 Kewanee Avenue	Lubbock	TX	Active
DSH450686F	Child	DSH	UNIVERSITY MEDICAL CENTER	Medication Therapy Management Clinic - ACC - Medication Therapy Management Clinic - Medication Therapy Management	808 Joliet Avenue	Lubbock	TX	Active
DSH450686G	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW Radiology - Diagnostic - 6140	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686H	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW Operating Room - 6021	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686J	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW Cath Lab - 6090	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686K	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW Radiology Special Procedures 6142	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686L	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW MRI - 6143	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686M	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW Ultrasound Lab - 6149	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686N	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW Cat Scan - 6150	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686P	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW Ambulatory Infusion - 6152	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686Q	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - Medication Therapy Management Clinic - Health and Wellness Hospital	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686R	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC HEALTH & WELLNESS HOSPITAL - HW Emergency Center - 6230	11011 SLIDE RD	LUBBOCK	TX	Active
DSH450686S	Child	DSH	UNIVERSITY MEDICAL CENTER	UMC Health & Wellness Hospital - Urgent Care Clinic	11102 Headquarters Drive	Lubbock	TX	Active
DSH450686T	Child	DSH	UNIVERSITY MEDICAL CENTER	LUBBOCK COUNTY DETENTION CENTER - General Medicine	3502 N Holly St	Lubbock	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Recertification		1417729708	8/20/2024 10:24 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/20/2024 10:24 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1831820893	8/20/2024 10:24 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/20/2024 10:24 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1861175564	8/20/2024 10:24 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/20/2024 10:24 AM
Details	Last Recertification Date	Update	Recertification	8/29/2023 8:49:04 PM	8/20/2024 10:24:00 AM	8/20/2024 10:24 AM
Addresses	Shipping Address	Insert	Change Request		UMC Pharmacy Health and Wellness 11011 Slide Road Lubbock, TX 79424	11/14/2023 7:42 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1831820893	10/31/2023 10:06 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		TX	10/31/2023 10:06 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1417729708	10/31/2023 10:06 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		TX	10/31/2023 10:06 AM
Addresses	Shipping Address	Insert	Recertification		UNIVERSITY MEDICAL CENTER 602 INDIANA AVE LUBBOCK, TX 79415	8/29/2023 8:49 PM
Addresses	Shipping Address	Insert	Recertification		UMC OUTPATIENT CENTER PHARMACY 7105 KEWANEE AVE LUBBOCK, TX 79424	8/29/2023 8:49 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1861175564	8/29/2023 8:49 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/29/2023 8:49 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 1:43:05 PM	8/29/2023 8:49:04 PM	8/29/2023 8:49 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1598900946 (NM)		1/6/2023 11:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1679521652	1/6/2023 11:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		NM	1/6/2023 11:11 AM
Details	Last Recertification Date	Update	Recertification	9/13/2021 4:29:24 PM	8/29/2022 1:43:05 PM	8/29/2022 1:43 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1598900946 (TX)		11/12/2021 9:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1679521652	11/12/2021 9:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		TX	11/12/2021 9:47 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1134364581 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1477576783 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1487993630 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1538245717 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1679521652 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1922355601 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1508855578 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1174620546 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1700828860 (TX)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1134364581 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1477576783 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1487993630 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1538245717 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1679521652 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1922355601 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1508855578 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1174620546 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1700828860 (NM)		9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1619561537	9/13/2021 4:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/13/2021 4:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1619561537	9/13/2021 4:29 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/13/2021 4:29 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 9:11:02 AM	9/13/2021 4:29:24 PM	9/13/2021 4:29 PM
Contacts	Authorizing Official	Update	Change Request	Johnson, Jim E Senior Vice President UMC Health System 8067758516	Lowe, John Vice President of Support Services University Medical Center 8067758516	1/19/2021 8:49 AM
Contacts	Primary Contact	Update	Change Request	HORNE, RUSSELL C DIRECTOR OF PHARMACY UMC Health System 8067759391	Armstrong, Courtney Director of Pharmacy University Medical Center 8067759391	12/2/2020 10:20 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1114991718 ( )		9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1477576783 ( )		9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1487993630 ( )		9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1134364581	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477576783	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1487993630	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1538245717	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598900946	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679521652	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821087164	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1922355601	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508855578	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1174620546	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700828860	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1134364581	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477576783	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1487993630	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1538245717	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598900946	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679521652	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821087164	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1922355601	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1508855578	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1174620546	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700828860	9/10/2020 9:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1821087164 ( )		9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1679521652 ( )		9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1538245717 ( )		9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1598900946 ( )		9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1134364581 ( )		9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1922355601 ( )		9/10/2020 9:11 AM
Details	Last Recertification Date	Update	Recertification	9/9/2019 8:40:16 AM	9/10/2020 9:11:02 AM	9/10/2020 9:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1114991718	9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477576783	9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1508855578 ( )		9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1972585016 ( )		9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1114991718 ( )		9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1700828860 ( )		9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1477576783 ( )		9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1730103250 ( )		9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1831299114 ( )		9/9/2019 8:40 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1174620546 ( )		9/9/2019 8:40 AM
Details	Last Recertification Date	Update	Recertification	8/28/2018 1:09:12 PM	9/9/2019 8:40:16 AM	9/9/2019 8:40 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/19/2018 6:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		137999206	9/19/2018 6:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	9/19/2018 6:03 PM
Details	Last Recertification Date	Update	Recertification	11/17/2017 10:45:05 AM	8/28/2018 1:09:12 PM	8/28/2018 1:09 PM
Contacts	Authorizing Official	Update	Change Request	ALLISON, DAVID CEO University Medical Center 8067758517	Johnson, Jim E Senior Vice President UMC Health System 8067758516	12/18/2017 11:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/17/2017 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		A9745	11/17/2017 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	11/17/2017 10:45 AM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/17/2017 10:45:05 AM	11/17/2017 10:45 AM
Contacts	Authorizing Official	Update		ALLISON, DAVID CEO 8067758517	ALLISON, DAVID CEO University Medical Center 8067758517	10/30/2017 11:01 AM
Contacts	Primary Contact	Update		HORNE, RUSSELL DIRECTOR OF PHARMACY 8067759391	HORNE, RUSSELL C DIRECTOR OF PHARMACY UMC Health System 8067759391	9/26/2017 12:57 PM
Contacts	Authorizing Official	Insert			ALLISON, DAVID CEO 8067758517	9/23/2016 12:09 PM
Addresses	Main Address	Insert			602 INDIANA AVE LUBBOCK, TX 79415	8/22/2016 5:31 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/22/2016 5:31 PM
Contacts	Primary Contact	Insert			HORNE, RUSSELL DIRECTOR OF PHARMACY 8067759391	8/22/2016 5:31 PM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 5:31 PM
Medicaid Billing	NPI: Number	Insert			1487993630	8/24/2015 5:09 PM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/24/2015 12:00:00 AM	8/24/2015 1:19 PM
Details	Last Recertification Date	Update		9/10/2013 12:00:00 AM	8/7/2014 12:00:00 AM	8/7/2014 3:15 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/10/2013 12:00:00 AM	9/10/2013 2:26 PM
Medicaid Billing	NPI: Number	Insert			1508855578	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1972585016	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1114991718	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1679521652	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1700828860	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1477576783	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1730103250	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1831299114	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1174620546	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1538245717	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1598900946	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1134364581	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1922355601	2/12/2013 1:05 PM
Dates	Participating Approval Date	Update		10/16/2007 6:08:29 AM	10/16/2007 12:00:00 AM	2/12/2013 1:05 PM
Medicaid Billing	NPI: Number	Insert			1821087164	5/17/2012 9:14 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/17/2012 9:14 AM
Details	Last Recertification Date	Insert				10/16/2007 6:11 AM
Details	Grant Number	Insert				10/16/2007 6:11 AM
Details	340B ID	Insert			DSH450686	10/16/2007 6:11 AM
Details	Is Authorizing Official EHB Data	Insert				10/16/2007 6:11 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/16/2007 6:11 AM
Details	Medicare Provider Number	Insert			450686	10/16/2007 6:11 AM
Details	Entity Name	Insert			UNIVERSITY MEDICAL CENTER	10/16/2007 6:11 AM
Details	Program Code	Insert			DSH	10/16/2007 6:11 AM
Details	Entity Subname	Insert				10/16/2007 6:11 AM
Dates	Participating Approval Date	Insert			10/16/2007 6:08:29 AM	10/16/2007 6:11 AM
Details	State	Insert			Active	10/16/2007 6:11 AM
Dates	Registration Date	Insert			10/16/2007 12:00:00 AM	10/16/2007 6:11 AM
Dates	Signed By Date	Insert				10/16/2007 6:11 AM
Dates	Start Date	Insert			12/1/1992 12:00:00 AM	10/16/2007 6:11 AM
Terminations	Termination Comments	Insert				10/16/2007 6:11 AM
Terminations	Termination Date	Insert				10/16/2007 6:11 AM
Terminations	Termination Effective Date	Insert				10/16/2007 6:11 AM
Terminations	Termination Reason	Insert				10/16/2007 6:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	10/16/2007 6:10 AM
Medicaid Billing	Medicaid: Number	Insert			250296	10/16/2007 6:10 AM
Medicaid Billing	Medicaid: State	Insert			TX	10/16/2007 6:10 AM