Covered Entity Details

CAH451305-00 CHI St. Joseph Health - Burleson Hospital (Active) - information as of 5/30/2025 6:46:46 PM

Main Details

Name

CHI St. Joseph Health - Burleson Hospital

Subdivision Name

Type

Critical Access Hospital

Rural

340B ID

CAH451305-00

Medicare Provider Number

451305

Additional Details

Current Program Status

Active

Registration Date

10/12/2012

Participating Start Date

1/1/2013

Participating Approval Date

10/18/2012

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

St. Joseph Regional Health Center
Erin Marietta, VP Operations
(443) 956-3099

Primary Contact

St. Joseph Regional Health Center
Kimberly Feese, Market Director Pharmacy
(979) 776-2506

Addresses

Street Address

1101 Woodson Dr
Caldwell, TX 77836

Billing Address

BURLESN ST JOSPH HLT CTR
PO BOX 2400
Phoenix, AZ 85002

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	112725003	1750377289

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	WAL-MART PHARMACY 10-0567	475 STATE HIGHWAY 36 NORTH		CALDWELL	TX	77836	02/28/2013	04/01/2013		08/11/2015	08/11/2015

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/22/2023 4:16:15 PM	8/26/2024 3:39:12 PM	8/26/2024 3:39 PM
Addresses	Billing Address	Update	Change Request	BURLESN ST JOSPH HLT CTR PO BOX 636000 LITTLETON, CO 80163-6000	BURLESN ST JOSPH HLT CTR PO BOX 2400 Phoenix, AZ 85002	5/15/2024 1:18 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 1:32:02 PM	8/22/2023 4:16:15 PM	8/22/2023 4:16 PM
Contacts	Authorizing Official	Update	Change Request	Diaz, Ricardo Chief Operating Officer CHI St. Joseph Regional Health Center 9797762580	Marietta, Erin VP Operations St. Joseph Regional Health Center 4439563099	7/26/2023 10:35 AM
Contacts	Primary Contact	Update	Change Request	Feese, Kimberly Market Director Pharmacy Madisonville St Joseph Health Center 9797762506	Feese, Kimberly Market Director Pharmacy St. Joseph Regional Health Center 9797762506	7/20/2023 2:34 PM
Contacts	Primary Contact	Update	Recertification	Feese, Kimberly Market Director Pharmacy Grimes St Joseph Health Center 9797762506	Feese, Kimberly Market Director Pharmacy Madisonville St Joseph Health Center 9797762506	9/6/2022 3:33 PM
Contacts	Primary Contact	Update	Recertification	Feese, Kimberly Market Director Pharmacy Burleson St Joseph Health Center 9797762506	Feese, Kimberly Market Director Pharmacy Grimes St Joseph Health Center 9797762506	9/6/2022 1:46 PM
Contacts	Primary Contact	Update	Recertification	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Burleson/Madison 9364991833	Feese, Kimberly Market Director Pharmacy Burleson St Joseph Health Center 9797762506	9/6/2022 1:32 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 9:58:36 AM	9/6/2022 1:32:02 PM	9/6/2022 1:32 PM
Addresses	Billing Address	Insert	Change Request		BURLESN ST JOSPH HLT CTR PO BOX 636000 LITTLETON, CO 80163-6000	4/27/2022 8:27 AM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Burleson/Grimes/Madison 9364991833	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Burleson/Madison 9364991833	4/18/2022 12:25 PM
Details	Last Recertification Date	Update	Recertification	8/23/2020 1:06:16 PM	9/7/2021 9:58:36 AM	9/7/2021 9:58 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1750377289	8/23/2020 1:06 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/23/2020 1:06 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1750377289 ( )		8/23/2020 1:06 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 10:16:08 AM	8/23/2020 1:06:16 PM	8/23/2020 1:06 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Burleson/Grimes/Madison 9797762511	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Burleson/Grimes/Madison 9364991833	10/15/2019 7:52 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Health 9797762511	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Burleson/Grimes/Madison 9797762511	9/30/2019 4:55 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Grimes Hospital 9368704524	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Health 9797762511	9/30/2019 4:51 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin Pharmacist in Charge CHI St. Joseph Grimes Hospital 9368704524	Williamson, Erin D. Pharmacist in Charge CHI St. Joseph Grimes Hospital 9368704524	9/30/2019 4:42 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin Pharmacist in Charge CHI St. Joseph Burleson/Grimes/Madison 9795672245	Williamson, Erin Pharmacist in Charge CHI St. Joseph Grimes Hospital 9368704524	9/30/2019 4:38 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245	Williamson, Erin Pharmacist in Charge CHI St. Joseph Burleson/Grimes/Madison 9795672245	9/25/2019 10:35 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 2:43:38 PM	9/5/2019 10:16:08 AM	9/5/2019 10:16 AM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245-9799364545	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245	7/29/2019 5:49 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245-9799364545	7/29/2019 5:49 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245-970654	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245	7/29/2019 5:48 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245-970654	7/29/2019 5:48 PM
Contacts	Primary Contact	Update	Profile Change Request	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health - Burleson Hospital 9795672245	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health Burleson/Madison 9795672245	7/29/2019 5:47 PM
Contacts	Primary Contact	Update	Change Request	Kocman, Brenda Pharmacist in Charge CHI St. Joseph Health - Madison Hospital 9363491659-0	Williamson, Erin Pharmacist in Charge CHI St. Joseph Health - Burleson Hospital 9795672245	12/12/2018 4:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/31/2018 11:21 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		112725003	8/31/2018 11:21 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	8/31/2018 11:21 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1750377289	8/31/2018 11:21 AM
Details	Entity Name	Update	Change Request	Burleson St. Joseph Health Center	CHI St. Joseph Health - Burleson Hospital	8/31/2018 11:21 AM
Contacts	Primary Contact	Update	Profile Change Request	Kocman, Brenda Pharmacist in Charge CHI St. Joseph Health - Burleson Hospital 9795672245-0	Kocman, Brenda Pharmacist in Charge CHI St. Joseph Health - Madison Hospital 9363491659-0	8/29/2018 6:39 PM
Contacts	Primary Contact	Update	Profile Change Request	Kocman, Brenda Pharmacist in Charge Burleson St. Joseph Health Care Center 9795672245-0	Kocman, Brenda Pharmacist in Charge CHI St. Joseph Health - Burleson Hospital 9795672245-0	8/29/2018 6:34 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 4:33:35 PM	8/22/2018 2:43:38 PM	8/22/2018 2:43 PM
Contacts	Authorizing Official	Update	Profile Change Request	Diaz, Ricardo Chief Operating Officer CHI St. Joseph Health Care Center\ 9797762580	Diaz, Ricardo Chief Operating Officer CHI St. Joseph Regional Health Center 9797762580	7/6/2018 7:30 PM
Contacts	Authorizing Official	Update	Profile Change Request	Diaz, Ricardo Chief Operating Officer Madison St. Joseph Health Care Center 9797762580	Diaz, Ricardo Chief Operating Officer CHI St. Joseph Health Care Center\ 9797762580	7/6/2018 7:29 PM
Contacts	Primary Contact	Update	Profile Change Request	Kocman, Brenda Pharmacist in Charge Madison St. Joseph Health Care Center 9363482631-0	Kocman, Brenda Pharmacist in Charge Burleson St. Joseph Health Care Center 9795672245-0	12/12/2017 4:13 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	12/4/2017 4:33:35 PM	12/4/2017 4:33 PM
Contacts	Primary Contact	Update		Kocman, Brenda Pharmacist in Charge 9363482631-0	Kocman, Brenda Pharmacist in Charge Madison St. Joseph Health Care Center 9363482631-0	10/16/2017 1:59 PM
Contacts	Authorizing Official	Update		Diaz, Ricardo Chief Operating Officer 9797762580	Diaz, Ricardo Chief Operating Officer Madison St. Joseph Health Care Center 9797762580	10/16/2017 12:12 PM
Contacts	Authorizing Official	Update		Krusie, Kathleen COO 9797762446	Diaz, Ricardo Chief Operating Officer 9797762580	6/30/2017 4:50 PM
Contacts	Primary Contact	Update		Hughson, John Administrator 9795673245-2201	Kocman, Brenda Pharmacist in Charge 9363482631-0	6/30/2017 4:50 PM
Addresses	Main Address	Insert			1101 Woodson Dr Caldwell, TX 77836	8/17/2016 1:21 PM
Contacts	Signed By	Insert			Hughson, John Administrator 9795672201-0	8/17/2016 1:21 PM
Details	Last Recertification Date	Update		8/7/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 1:21 PM
Details	Last Recertification Date	Update		8/20/2014 12:00:00 AM	8/7/2015 12:00:00 AM	8/7/2015 7:01 AM
Contacts	Authorizing Official	Update		Hughson, John Administrator 9795673245-2201	Krusie, Kathleen COO 9797762446	9/8/2014 1:43 PM
Contacts	Authorizing Official	Update		Hughson, John Administrator 9795672201-0	Hughson, John Administrator 9795673245-2201	8/20/2014 11:47 AM
Contacts	Primary Contact	Update		Hughson, John Administrator 9795672201-0	Hughson, John Administrator 9795673245-2201	8/20/2014 11:47 AM
Details	Last Recertification Date	Update		9/11/2013 12:00:00 AM	8/20/2014 12:00:00 AM	8/20/2014 11:47 AM
Details	Last Recertification Date	Update			9/11/2013 12:00:00 AM	9/11/2013 9:54 AM
Contacts	Authorizing Official	Insert			Hughson, John Administrator 9795672201-0	9/11/2013 9:35 AM
Contacts	Primary Contact	Insert			Hughson, John Administrator 9795672201-0	9/11/2013 9:35 AM
Details	340B ID	Update		ISDMCAH451305-00	CAH451305-00	10/18/2012 11:01 AM
Dates	Participating Approval Date	Update			10/18/2012 12:00:00 AM	10/18/2012 11:01 AM
Details	State	Update		Pending	Active	10/18/2012 11:01 AM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	10/18/2012 11:01 AM
Details	340B ID	Update		DM101512A	ISDMCAH451305-00	10/15/2012 11:03 AM
Details	340B ID	Update		DM101212B	DM101512A	10/15/2012 8:04 AM
Details	340B ID	Update		ONLINE_REG	DM101212B	10/12/2012 5:20 PM
Details	Last Recertification Date	Insert				10/12/2012 4:45 PM
Details	Grant Number	Insert				10/12/2012 4:45 PM
Details	340B ID	Insert			ONLINE_REG	10/12/2012 4:45 PM
Details	Is Authorizing Official EHB Data	Insert				10/12/2012 4:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/12/2012 4:45 PM
Details	Medicare Provider Number	Insert			451305	10/12/2012 4:45 PM
Details	Entity Name	Insert			Burleson St. Joseph Health Center	10/12/2012 4:45 PM
Details	Program Code	Insert			CAH	10/12/2012 4:45 PM
Details	Entity Subname	Insert				10/12/2012 4:45 PM
Dates	Participating Approval Date	Insert				10/12/2012 4:45 PM
Details	State	Insert			Pending	10/12/2012 4:45 PM
Dates	Registration Date	Insert			10/12/2012 12:00:00 AM	10/12/2012 4:45 PM
Dates	Signed By Date	Insert			10/12/2012 12:00:00 AM	10/12/2012 4:45 PM
Dates	Start Date	Insert				10/12/2012 4:45 PM
Terminations	Termination Comments	Insert				10/12/2012 4:45 PM
Terminations	Termination Date	Insert				10/12/2012 4:45 PM
Terminations	Termination Effective Date	Insert				10/12/2012 4:45 PM
Terminations	Termination Reason	Insert				10/12/2012 4:45 PM