Covered Entity Details

DSH450021 BAYLOR UNIVERSITY MEDICAL CTR (Active) - information as of 4/27/2025 1:46:33 AM

Main Details

Name

BAYLOR UNIVERSITY MEDICAL CTR

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450021

Medicare Provider Number

450021

Additional Details

Current Program Status

Active

Registration Date

1/6/2023

Participating Start Date

3/7/2023

Participating Approval Date

3/6/2023

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Baylor University Medical Center
Kyle Armstrong, President
(214) 820-3101

Primary Contact

Baylor University Medical Center
Dana Radman, Director of Pharmacy
(214) 820-2968

Addresses

Street Address

3500 GASTON AVENUE
DALLAS, TX 75246

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 10/01/2010; Terminated 4/1/2017; Reinstated 3/7/2023.	03/07/2023

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	139485012	1447250253

Shipping Addresses

Shipping Address 1

Safecor Health, LLC.
4060 Business Park Drive
Columbus, OH 43204

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/12/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/12/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/12/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/12/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/12/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/12/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/12/2023	07/01/2023		07/01/2023
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #101	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	3600 GASTON AVE STE 109	DALLAS	TX	75246	10/04/2010	10/04/2010	04/01/2017	01/19/2017
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #101	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	3600 GASTON AVE STE 109	DALLAS	TX	75246	03/06/2023	03/07/2023		03/07/2023
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #102	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	1250 8TH AVE STE 125	FORT WORTH	TX	76104	07/18/2023	10/01/2023		10/01/2023
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #103	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	3410 WORTH ST STE 240	DALLAS	TX	75246	04/20/2011	05/01/2011	04/01/2017	01/19/2017
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #103	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	3410 WORTH ST STE 240	DALLAS	TX	75246	03/06/2023	03/07/2023		03/07/2023
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #110	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	2460 N INTERSTATE HIGHWAY 35 E STE 155	WAXAHACHIE	TX	75165	07/18/2023	10/01/2023		10/01/2023
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #111	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	3417 GASTON AVE STE 195	DALLAS	TX	75246	03/06/2023	03/07/2023		03/07/2023
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #113	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	3800 GAYLORD PKWY STE 110	FRISCO	TX	75034	03/06/2023	03/07/2023		03/07/2023
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #201	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	425 UNIVERSITY BLVD STE 165	ROUND ROCK	TX	78665	04/12/2023	07/01/2023		07/01/2023
Contract Detail	BAYLOR SCOTT & WHITE PHARMACY #227	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	937 CANYON CREEK DR	TEMPLE	TX	76502	04/10/2024	07/01/2024		07/01/2024
Contract Detail	BAYLOR SCOTT & WHITE SPECIALTY PHARMACY	BAYLOR SCOTT & WHITE HEALTH ENTERPRISES,	3161 EAGLES NEST ST UNIT 340	ROUND ROCK	TX	78665	04/12/2023	07/01/2023	10/29/2024	10/31/2024
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/12/2023	07/01/2023		07/01/2023
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/12/2023	07/01/2023		07/01/2023
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/12/2023	07/01/2023		07/01/2023
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/12/2023	07/01/2023		07/01/2023
Contract Detail	ONCO360	SINA DRUG, LLC	4700 W SAM HOUSTON PKWY N STE 150	HOUSTON	TX	77041	10/11/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/14/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/14/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/14/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/14/2023	07/01/2023		07/01/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/14/2023	07/01/2023		07/01/2023
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	10/11/2024	01/01/2025		01/01/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH450021A	Child	DSH	BAYLOR UNIVERSITY MEDICAL CENTER	Weight Loss Surgery Clinic	9101 N. Central Expressway	Dallas	TX	Terminated
DSH450021B	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	Headache/Movement Disorder Clinic	9101 N. Central Expressway	Dallas	TX	Active
DSH450021C	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	Breast Imaging Center - North Dallas	9101 N. Central Expressway	Dallas	TX	Active
DSH450021D	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	Breast Imaging Center - Junius	3900 Junius	Dallas	TX	Active
DSH450021E	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	Martha Foster Lung Center	3410 Worth St.	Dallas	TX	Active
DSH450021F	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	Apheresis Lab	3535 Worth St.	Dallas	TX	Approved
DSH450021G	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	BUMC ENDOSCOPY - GASTROENTEROLOGY LAB	3501 Junius	Dallas	TX	Active
DSH450021H	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	VISUAL FUNCTION CENTER - Visual Function Test Center	3600 GASTON AVE	DALLAS	TX	Active
DSH450021J	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	PULMONARY REHAB - PHY Medicine Outpatient Cancer Center	3410 Worth St.	Dallas	TX	Active
DSH450021K	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	ONCOLOGY INFUSION CENTER - BUMC Oncology Infusion Center	3535 Worth St.	Dallas	TX	Active
DSH450021L	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	GI PHYSIOLOGY LAB - GI PHYSIOLOGY	3600 GASTON AVE	DALLAS	TX	Active
DSH450021M	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	COMPREHENSIVE WOUND CNTR/HYPERBARIC - Hyperbaric Chamber Barnett 2	3600 GASTON AVE	DALLAS	TX	Active
DSH450021N	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	ABDOMINAL TRANSPLANT CLINIC - Transplant Clinic (Abdominal)	3410 WORTH ST	DALLAS	TX	Active
DSH450021P	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	BUMC EKG - BUMC EKG	3600 Gaston Avenue	Dallas	TX	Active
DSH450021Q	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	BAYLOR MEMORY CENTER - Memory and Alzheimer's Center	9101 N CENTRAL EXPY	DALLAS	TX	Active
DSH450021R	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	BUMC Vascular Interventional - Interventional Radiology	3501 Junius	Dallas	TX	Active
DSH450021S	Child	DSH	BAYLOR UNIVERSITY MEDICAL CTR	CNTR FOR ADVANCED HEART&LUNG DISEAS - BUMC Transplant Cardiothoracic	3410 WORTH ST	DALLAS	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/1/2023 11:33:06 AM	8/21/2024 3:13:52 PM	8/21/2024 3:13 PM
Addresses	Shipping Address	Insert	Change Request		Safecor Health, LLC. 4060 Business Park Drive Columbus, OH 43204	2/7/2024 9:25 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1006724 (AK)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (AZ)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	113217105 (AR)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (CA)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	95010633 (CO)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	008050845 (CT)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	008049952 (CT)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	904853700 (FL)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003201463A (GA)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	587503 (HI)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (ID)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	751837454001 (IL)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300025822 (IN)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0548206 (IA)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7100016820 (KY)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1745715 (LA)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (ME)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	330404300 (MD)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (MI)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (MN)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	004436083 (MS)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	012215109 (MO)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10025732500 (NE)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (NV)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0122572 (NJ)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	A1395 (NM)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	03005709 (NY)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (NC)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0794716 (OH)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100702580B (OK)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (OR)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000856618-0001 (PA)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7250253 (RI)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	131170 (SD)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11179A (SC)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	751837454009 (UT)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1447250253 (VA)		1/8/2024 4:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2195420 (WA)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (AK)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (AZ)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (AR)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (CA)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (CO)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (CT)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (FL)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (GA)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (HI)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (ID)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (IL)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (IN)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (IA)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (KY)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (LA)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (ME)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (MD)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (MI)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (MN)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (MS)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (MO)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (NE)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (NV)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (NJ)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (NM)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (NY)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (NC)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (OH)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (OK)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (OR)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (PA)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (RI)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (SC)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (SD)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (UT)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (VA)		1/8/2024 4:40 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1447250253 (WA)		1/8/2024 4:40 PM
Details	Last Recertification Date	Update	Recertification		9/1/2023 11:33:06 AM	9/1/2023 11:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1006724	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AK	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		113217105	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		95010633	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008050845	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008049952	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		904853700	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003201463A	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		587503	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		HI	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		751837454001	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300025822	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0548206	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100016820	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1745715	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		330404300	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		004436083	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		012215109	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10025732500	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0122572	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		A1395	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03005709	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0794716	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100702580B	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000856618-0001	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		RI	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		131170	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SD	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11179A	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		751837454009	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2195420	3/19/2023 9:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		AK	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		HI	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		SD	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	3/19/2023 9:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1447250253	3/19/2023 9:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	3/19/2023 9:09 PM
Details	Comments Public	Insert	OPA Edit		Participated starting 10/01/2010; Terminated 4/1/2017; Reinstated 3/7/2023.	3/7/2023 9:41 AM
Details	State	Update	OPA Edit	Approved	Active	3/7/2023 6:33 AM
Dates	Start Date	Update	OPA Edit	4/1/2023 12:00:00 AM	3/7/2023 12:00:00 AM	3/7/2023 6:33 AM
Addresses	Main Address	Update	Reinstatement	3500 GASTON AVE DALLAS, TX 75246	3500 GASTON AVENUE DALLAS, TX 75246	3/6/2023 2:46 PM
Contacts	Primary Contact	Update	Reinstatement	Starr, Kirk Director of Pharmacy 2148202968	Radman, Dana Director of Pharmacy Baylor University Medical Center 2148202968	3/6/2023 2:46 PM
Contacts	Authorizing Official	Update	Reinstatement	Lawson, Douglas T. PRESIDENT 2148203101	Armstrong, Kyle President Baylor University Medical Center 2148203101	3/6/2023 2:46 PM
Contacts	Signed By	Insert	Reinstatement		Armstrong, Kyle President Baylor University Medical Center 2148203101	3/6/2023 2:46 PM
Details	Last Recertification Date	Update	Reinstatement	8/19/2016 12:00:00 AM		3/6/2023 2:46 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	11/30/2016 12:00:00 AM		3/6/2023 2:46 PM
Details	Entity Name	Update	Reinstatement	BAYLOR UNIVERSITY MEDICAL CENTER	BAYLOR UNIVERSITY MEDICAL CTR	3/6/2023 2:46 PM
Dates	Participating Approval Date	Update	Reinstatement	9/16/2010 12:00:00 AM	3/6/2023 2:46:17 PM	3/6/2023 2:46 PM
Details	State	Update	Reinstatement	Terminated	Approved	3/6/2023 2:46 PM
Dates	Registration Date	Update	Reinstatement	9/16/2010 12:00:00 AM	1/6/2023 10:28:40 AM	3/6/2023 2:46 PM
Dates	Signed By Date	Update	Reinstatement	8/25/2010 12:00:00 AM	1/9/2023 5:47:36 PM	3/6/2023 2:46 PM
Dates	Start Date	Update	Reinstatement	10/1/2010 12:00:00 AM	4/1/2023 12:00:00 AM	3/6/2023 2:46 PM
Terminations	Termination Comments	Update	Reinstatement	11/30/16 DSH%--11.09%Resubmitting term as submitted 12/1/16		3/6/2023 2:46 PM
Terminations	Termination Date	Update	Reinstatement	4/1/2017 12:00:00 AM		3/6/2023 2:46 PM
Terminations	Termination Effective Date	Update	Reinstatement	12/1/2016 12:00:00 AM		3/6/2023 2:46 PM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		3/6/2023 2:46 PM
Addresses	Main Address	Insert			3500 GASTON AVE DALLAS, TX 75246	1/19/2017 3:09 PM
Contacts	Primary Contact	Update		Whittey, Janet Director of Pharmacy 2148208296	Starr, Kirk Director of Pharmacy 2148202968	1/19/2017 3:09 PM
Contacts	Authorizing Official	Insert			Lawson, Douglas T. PRESIDENT 2148203101	1/19/2017 3:09 PM
Dates	Last Date That 340B Drugs Purchased	Update			11/30/2016 12:00:00 AM	1/19/2017 3:09 PM
Details	State	Update		Active	Terminated	1/19/2017 3:09 PM
Terminations	Termination Comments	Update			11/30/16 DSH%--11.09%Resubmitting term as submitted 12/1/16	1/19/2017 3:09 PM
Terminations	Termination Date	Update			4/1/2017 12:00:00 AM	1/19/2017 3:09 PM
Terminations	Termination Effective Date	Update			12/1/2016 12:00:00 AM	1/19/2017 3:09 PM
Terminations	Termination Reason	Update			DSH percentage below statutory minimum	1/19/2017 3:09 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/19/2016 4:18 PM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	8/19/2016 12:00:00 AM	8/19/2016 4:18 PM
Details	Last Recertification Date	Update		9/5/2014 12:00:00 AM	9/2/2015 12:00:00 AM	9/2/2015 1:50 PM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	9/5/2014 12:00:00 AM	9/5/2014 6:26 PM
Contacts	Primary Contact	Update		HILKERT, CARLA PHARMACY MANAGER 2148206702	Whittey, Janet Director of Pharmacy 2148208296	9/9/2013 2:53 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 2:53 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/18/2012 12:20 PM
Contacts	Primary Contact	Insert			HILKERT, CARLA PHARMACY MANAGER 2148206702	9/16/2010 12:27 PM
Details	Last Recertification Date	Insert				9/16/2010 12:27 PM
Details	Grant Number	Insert				9/16/2010 12:27 PM
Details	340B ID	Insert			DSH450021	9/16/2010 12:27 PM
Details	Is Authorizing Official EHB Data	Insert				9/16/2010 12:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/16/2010 12:27 PM
Details	Medicare Provider Number	Insert			450021	9/16/2010 12:27 PM
Details	Entity Name	Insert			BAYLOR UNIVERSITY MEDICAL CENTER	9/16/2010 12:27 PM
Details	Program Code	Insert			DSH	9/16/2010 12:27 PM
Details	Entity Subname	Insert				9/16/2010 12:27 PM
Dates	Participating Approval Date	Insert			9/16/2010 12:00:00 AM	9/16/2010 12:27 PM
Details	State	Insert			Active	9/16/2010 12:27 PM
Dates	Registration Date	Insert			9/16/2010 12:00:00 AM	9/16/2010 12:27 PM
Dates	Signed By Date	Insert			8/25/2010 12:00:00 AM	9/16/2010 12:27 PM
Dates	Start Date	Insert			10/1/2010 12:00:00 AM	9/16/2010 12:27 PM
Terminations	Termination Comments	Insert				9/16/2010 12:27 PM
Terminations	Termination Date	Insert				9/16/2010 12:27 PM
Terminations	Termination Effective Date	Insert				9/16/2010 12:27 PM
Terminations	Termination Reason	Insert				9/16/2010 12:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	9/16/2010 10:33 AM
Medicaid Billing	Medicaid: Number	Insert			139485012	9/16/2010 10:33 AM
Medicaid Billing	Medicaid: State	Insert			TX	9/16/2010 10:33 AM