Covered Entity Details

PED453302-08 CHILDREN'S MEDICAL CENTER DALLAS (Terminated) - information as of 4/29/2025 12:33:00 AM

Main Details

Name

CHILDREN'S MEDICAL CENTER DALLAS

Subdivision Name

CHILDREN'S AMBULATORY CARE PAVILION AT LEGACY

Type

Children's Hospital

Rural

340B ID

PED453302-08

Medicare Provider Number

453302

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

3/29/2010

Participating Start Date

4/1/2010

Participating Approval Date

3/30/2010

Last Recertification Date

8/7/2014

Termination Date
Termination Reason

7/1/2015
Site closure

Contacts

Authorizing Official

Children's Health
David T Berry, CHST President, System Clinical Operations
(214) 456-2143

Primary Contact

Children's Health System of Texas
Michelle Kromelis, Senior Director of Pharmacy
(214) 456-6203

Addresses

Street Address

7601 PRESTON ROAD
PLANO, TX 75024

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
5/28/2010- UPDATED THE SUB-DIV. NAME (CHILDREN'S MEDICAL CENTER LEGACY)	09/14/2010

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	13890807
		1194743013

Shipping Addresses

Shipping Address 1

PAVILION SURGERY CENTER PHARMACY
2350 STEMMONS FREEWAY
DALLAS, TX 75207

Shipping Address 2

FIRST PHARMACY
1935 MEDICAL DISTRICT DR
DALLAS, TX 75235

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
PED453302-01	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S MEDICAL CENTER LEGACY	7601 PRESTON ROAD	PLANO	TX	Terminated
PED453302-02	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	DALLAS AMBULATORY CARE PAVILION	2350 STEMMONS FREEWAY	DALLAS	TX	Terminated
PED453302-03	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	DESOTO SPECIALTY CENTER	2828 DUKE OF GLOUCHESTER STREET	DESOTO	TX	Terminated
PED453302-04	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	IRVING SPECIALTY CENTER	400 I-635 E	IRVING	TX	Terminated
PED453302-05	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	MESQUITE SPECIALTY CENTER	1600 REPUBLIC PKWY	MESQUITE	TX	Terminated
PED453302-06	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHASE SPECIALTY CENTER	6300 HARRY HINES BOULEVARD	DALLAS	TX	Terminated
PED453302-07	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	PAVILION SURGERY CENTER	2350 North Stemmons Freeway	DALLAS	TX	Active
PED453302-08	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S AMBULATORY CARE PAVILION AT LEGACY	7601 PRESTON ROAD	PLANO	TX	Terminated
PED453302-09	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S AMBULATORY SURGERY CENTER AT SOUTHLAKE	470 E STATE HIGHWAY 114	SOUTHLAKE	TX	Terminated
PED453302-10	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Dallas Campus / Perioperative Clinic	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-11	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center at Cityville Physical Medicine & Rehabilitation/Outpatient Therapy	2222 Medical District Drive	Dallas	TX	Active
PED453302-12	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center at Cityville, Specialty Clinics	2222 Medical District Drive	Dallas	TX	Active
PED453302-13	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pavilion Imaging Center, Diagnostics	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-14	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pavilion Imaging Center, MRI	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-15	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pavilion Imaging Center, Utrasound	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-16	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pulmonary Lab	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-17	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Sleep Disorders Center	2620 North Stemmons Freeway	Dallas	TX	Active
PED453302-18	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Adolescent & Young Adult Clinic	2350 North Stemmons Freeway	Dallas	TX	Terminated
PED453302-19	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Audiology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-20	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Cystic Fibrosis	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-21	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Dermatology	2350 North Stemmons Freeway	Dallas	TX	Terminated
PED453302-22	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / General Surgery	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-23	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pain Management	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-24	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pulmonary	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-25	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Allergy/Immunology/Asthma Clinic	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-26	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Genetics / Metabolics	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-27	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Diabetes/Endocrinology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-28	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Ears, Nose & Throat	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-29	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Eye Clinic/Ophthalmology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-30	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Rheumatology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-31	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Gastroenterology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-32	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Plastic & Craniofacial Surgery/Plastic Hand	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-33	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Orthopedics	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-34	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Neurology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-35	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Special Procedures	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-36	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / COACH (Center for Obesity and its Consequences in Health)	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-37	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Mockingbird 1 / Psychiatry/ Psychology	1341 West Mockingbird Lane, Suite 1200E	Dallas	TX	Active
PED453302-38	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Mockingbird 1; Center for Autism and Developmental Disabilities / Autism/Intensive Outpatient Autism	1341 West Mockingbird Lane, Suite 240W	Dallas	TX	Active
PED453302-39	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Mockingbird 1; Psychiatry Day Treatment	1341 West Mockingbird Lane, Suite 500E	Dallas	TX	Active
PED453302-40	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S HEALTH SPECIALTY CENTER, Park Cities	8160 WALNUT HILL LN 106	DALLAS	TX	Active
PED453302-41	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center, Dallas Campus / Urology Clinic	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-42	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center, Dallas Campus / Adolescent & Gynecology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-43	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center, Dallas Campus / Foster Care Clinic (Rees-Jones Center for Foster Care Excellence)	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-44	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center, South Rockwall - Urology Clinic	1005 West Ralph Hall Parkway	Rockwall	TX	Terminated
PED453302-45	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S HEALTH SPECIALTY CENTER - Epilepsy Clinic, Suite F5400	2350 N STEMMONS FWY	DALLAS	TX	Terminated
PED453302-46	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S HEALTH SPECIALTY CENTER - Neuropsychology Clinic, Suite F5000	2350 N STEMMONS FWY	DALLAS	TX	Active

History

Section	Field	Action	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Berry, David CHST President, System Clinical Operations 2144562143	Berry, David T CHST President, System Clinical Operations Children's Health 2144562143	10/10/2017 9:42 AM
Contacts	Primary Contact	Update	Kromelis, Michelle Senior Director of Pharmacy 2144566203	Kromelis, Michelle Senior Director of Pharmacy Children's Health System of Texas 2144566203	10/9/2017 2:55 PM
Contacts	Authorizing Official	Update	Eager, David SVP Finance & CFO 2144567890	Berry, David CHST President, System Clinical Operations 2144562143	9/11/2017 3:29 PM
Contacts	Primary Contact	Insert		Kromelis, Michelle Senior Director of Pharmacy 2144566203	5/10/2017 6:31 AM
Contacts	Authorizing Official	Insert		Eager, David SVP Finance & CFO 2144567890	5/10/2017 6:31 AM
Addresses	Main Address	Insert		7601 PRESTON ROAD PLANO, TX 75024	4/14/2015 3:22 PM
Addresses	Shipping Address	Insert		PAVILION SURGERY CENTER PHARMACY 2350 STEMMONS FREEWAY DALLAS, TX 75207	4/14/2015 3:22 PM
Addresses	Shipping Address	Insert		FIRST PHARMACY 1935 MEDICAL DISTRICT DR DALLAS, TX 75235	4/14/2015 3:22 PM
Dates	Last Date That 340B Drugs Purchased	Update		4/6/2015 12:00:00 AM	4/14/2015 3:21 PM
Details	State	Update	Active	Terminated	4/14/2015 3:21 PM
Terminations	Termination Comments	Update		Children's Medical Center Legacy Campus located at 7601 Preston Road in Plano Texas will be operating under it's own provider # as of 4/7/2015. As such the two child sites: PED453302-01 and PED453302-08 will no longer be child sites of the parent entity listed as Childrens Medical Center Dallas (PED453302-00). Instead, this hospital will qualify for 340B under its own provider number and will be registered as such.	4/14/2015 3:21 PM
Terminations	Termination Date	Update		7/1/2015 12:00:00 AM	4/14/2015 3:21 PM
Terminations	Termination Effective Date	Update		4/7/2015 12:00:00 AM	4/14/2015 3:21 PM
Terminations	Termination Reason	Update		Site closure	4/14/2015 3:21 PM
Details	Last Recertification Date	Update	9/3/2013 10:04:29 AM	8/7/2014 12:00:00 AM	8/7/2014 11:27 AM
Details	Last Recertification Date	Update	7/1/2012 12:00:00 AM	9/3/2013 10:04:29 AM	9/3/2013 10:04 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	5/4/2012 8:24 AM
Details	Last Recertification Date	Insert			9/14/2010 3:20 PM
Details	Grant Number	Insert			9/14/2010 3:20 PM
Details	340B ID	Insert		PED453302-08	9/14/2010 3:20 PM
Details	Is Authorizing Official EHB Data	Insert			9/14/2010 3:20 PM
Dates	Last Date That 340B Drugs Purchased	Insert			9/14/2010 3:20 PM
Details	Medicare Provider Number	Insert		453302	9/14/2010 3:20 PM
Details	Entity Name	Insert		CHILDREN'S MEDICAL CENTER DALLAS	9/14/2010 3:20 PM
Details	Program Code	Insert		PED	9/14/2010 3:20 PM
Details	Entity Subname	Insert		CHILDREN'S AMBULATORY CARE PAVILION AT LEGACY	9/14/2010 3:20 PM
Dates	Participating Approval Date	Insert		3/30/2010 12:00:00 AM	9/14/2010 3:20 PM
Details	State	Insert		Active	9/14/2010 3:20 PM
Dates	Registration Date	Insert		3/29/2010 12:00:00 AM	9/14/2010 3:20 PM
Dates	Signed By Date	Insert		3/1/2010 12:00:00 AM	9/14/2010 3:20 PM
Dates	Start Date	Insert		4/1/2010 12:00:00 AM	9/14/2010 3:20 PM
Terminations	Termination Comments	Insert			9/14/2010 3:20 PM
Terminations	Termination Date	Insert			9/14/2010 3:20 PM
Terminations	Termination Effective Date	Insert			9/14/2010 3:20 PM
Terminations	Termination Reason	Insert			9/14/2010 3:20 PM
Details	Comments Public	Insert		5/28/2010- UPDATED THE SUB-DIV. NAME (CHILDREN'S MEDICAL CENTER LEGACY)	9/14/2010 3:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert		True	3/29/2010 3:50 PM
Medicaid Billing	Medicaid: Number	Insert		13890807	3/29/2010 3:50 PM
Medicaid Billing	Medicaid: State	Insert		TX	3/29/2010 3:50 PM
Medicaid Billing	NPI: Number	Insert		1194743013	3/29/2010 3:50 PM