Covered Entity Details

PED453300-32 COOK CHILDREN'S MEDICAL CENTER (Terminated) - information as of 6/6/2025 4:27:15 AM

Main Details

Name

COOK CHILDREN'S MEDICAL CENTER

Subdivision Name

Lewisville Specialty Clinic ~ Behavioral Health Clinic

Type

Children's Hospital

Rural

340B ID

PED453300-32

Medicare Provider Number

453300

Outpatient Facility Provider Number

453300

Additional Details

Current Program Status

Terminated

Registration Date

10/9/2013

Participating Start Date

1/1/2014

Participating Approval Date

12/12/2013

Last Recertification Date

11/9/2017

Termination Date
Termination Reason

7/1/2018
Site closure

Contacts

Authorizing Official

Cook Children's Medical Center
Nancy Cychol, EVP, Hospital Services
(682) 885-4340

Primary Contact

Cook Children's Medical Center
Adriana Martinez, 340B Program Manager
(682) 885-2167

Addresses

Street Address

401 N. Valley Pkwy, Suite #400
Lewisville, TX 75067

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	021184901
OK	100702730A
		1891765178,1942509963

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED453300-01	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Grapevine ~ Hematology & Oncology	1600 W Northwest Highway, Ste 500	Grapevine	TX	Terminated
PED453300-03	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Apheresis	1500 Cooper St	Fort Worth	TX	Active
PED453300-04	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Stem Cell	1500 Cooper St	Fort Worth	TX	Active
PED453300-05	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Radiology and Imaging Center	1500 Cooper St	Fort Worth	TX	Terminated
PED453300-06	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Cardiology Heart Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-07	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Craniofacial	1500 Cooper St	Fort Worth	TX	Active
PED453300-08	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Endocrinology	1500 Cooper St	Fort Worth	TX	Active
PED453300-09	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Gastroenterology & Nutrition	1500 Cooper St	Fort Worth	TX	Active
PED453300-10	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Hematology & Oncology	1500 Cooper St	Fort Worth	TX	Active
PED453300-11	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Infectious Disease	1500 Cooper St	Fort Worth	TX	Active
PED453300-12	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Nephrology	1500 Cooper St	Fort Worth	TX	Active
PED453300-13	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Dialysis	1500 Cooper St	Fort Worth	TX	Active
PED453300-14	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neuropsychology	1500 Cooper St	Fort Worth	TX	Active
PED453300-15	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neurosciences	1500 Cooper St	Fort Worth	TX	Active
PED453300-16	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Pain Management	1500 Cooper St	Fort Worth	TX	Active
PED453300-17	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Pediatric Surgery	1500 Cooper St	Fort Worth	TX	Active
PED453300-18	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Behavioral Health Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-19	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Southlake ~ Behavioral Health Clinic	2727 E Southlake Blvd	Southlake	TX	Active
PED453300-20	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Pulmonary Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-21	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Rheumatology	1500 Cooper St	Fort Worth	TX	Active
PED453300-22	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Ambulatory Surgery Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-23	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Infusion Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-24	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Hemophilia	1500 Cooper St	Fort Worth	TX	Terminated
PED453300-25	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neuro Oncology	1500 Cooper St	Fort Worth	TX	Active
PED453300-26	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neuro Psych	1500 Cooper St	Fort Worth	TX	Terminated
PED453300-27	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Arlington Specialty Clinic - Cardiology Heart Center	3121 S. Center St	Arlington	TX	Active
PED453300-28	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Denton Specialty Clinic ~ Behavioral Health Clinic	3304 Colorado Blvd Suite #102	Denton	TX	Active
PED453300-29	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Southwest Specialty Clinic ~ Behavioral Health Clinic	6210 John Ryan Dr Suite #106	Fort Worth	TX	Active
PED453300-31	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Hurst Specialty Clinic ~ Behavioral Health Clinic	750 Mid Cities Boulevard	Hurst	TX	Active
PED453300-32	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Lewisville Specialty Clinic ~ Behavioral Health Clinic	401 N. Valley Pkwy, Suite #400	Lewisville	TX	Terminated
PED453300-35	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Ear Nose and Throat Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-36	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Teddy Bear Transport	124 Texas Way	Fort Worth	TX	Active
PED453300-37	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Specialty Clinic South ~ Partial Hospital Program	901 Seventh Ave	Fort Worth	TX	Terminated
PED453300-38	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Cardiology Outreach	1500 Cooper St	Fort Worth	TX	Terminated
PED453300-39	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ REACH Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-40	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Alexander Vision Center ~ Ophthalmology	321 S. Henderson St	Fort Worth	TX	Terminated
PED453300-41	Child	PED	COOK CHILDREN'S MEDICAL CENTER	McCart Neighborhood Clinic ~ Behavioral Health Clinic	6421 McCart Ave	Fort Worth	TX	Terminated
PED453300-42	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ NEST Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-43	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Mansfield / Behavioral Health Clinic	801 Matlock Road	Mansfield	TX	Active
PED453300-44	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Motion Analysis Lab	1401 W Pulaski St	Fort Worth	TX	Active
PED453300-45	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Dermatology	1500 Cooper St	Fort Worth	TX	Active
PED453300-46	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Sleep Medicine Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-47	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic - Genitourinary	1500 Cooper St	Fort Worth	TX	Active
PED453300-48	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Alliance Behavioral Health - Psych	10601 North Riverside Drive	Fort Worth	TX	Active
PED453300-49	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neurodiagnostic	1500 Cooper St	Fort Worth	TX	Active
PED453300-50	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Neurosurgery	1500 Cooper St	Fort Worth	TX	Active
PED453300-51	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Immunology	1500 Cooper St	Fort Worth	TX	Active
PED453300-52	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Wound Care	1500 Cooper St	Fort Worth	TX	Active
PED453300-53	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Foster Health Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-54	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ CARE Team Clinic	1500 Cooper St	Fort Worth	TX	Active
PED453300-55	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Trauma	1500 Cooper St	Fort Worth	TX	Active
PED453300-56	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Psychology- AYA	1500 Cooper St	Fort Worth	TX	Active
PED453300-57	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Ambulatory Surgery Center Anesthesia	1500 Cooper St	Fort Worth	TX	Active
PED453300-58	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Ambulatory Surgery Center Radiology	1500 Cooper St	Fort Worth	TX	Active
PED453300-59	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Prader-Willi Center	1500 Cooper St	Fort Worth	TX	Active
PED453300-60	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic ~ Complex Care	1500 Cooper St	Fort Worth	TX	Active
PED453300-61	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic - Developmental Pediatrics	1500 Cooper St	Fort Worth	TX	Approved
PED453300-62	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic - Genetic Oncology	1500 Cooper St	Fort Worth	TX	Approved
PED453300-63	Child	PED	COOK CHILDREN'S MEDICAL CENTER	Dodson Specialty Clinic - Metabolic & Genetic Bone Health	1500 Cooper St	Fort Worth	TX	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Cychol, Nancy President Cook Children's Medical Center 6828854340	Cychol, Nancy EVP, Hospital Services Cook Children's Medical Center 6828854340	7/7/2023 12:56 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/29/2017 12:00:00 AM	6/4/2018 11:31 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/4/2018 11:31 AM
Terminations	Termination Comments	Update	Termination Request		Site closed at the end of September 2017. Providers re-located to other CCMC behavioral clinics.	6/4/2018 11:31 AM
Terminations	Termination Date	Update	Termination Request		7/1/2018 12:00:00 AM	6/4/2018 11:31 AM
Terminations	Termination Effective Date	Update	Termination Request		9/29/2017 12:00:00 AM	6/4/2018 11:31 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	6/4/2018 11:31 AM
Contacts	Primary Contact	Update	Profile Change Request	Martinez, Adriana 340B Program Manager Cook Childrens Medical Center 6828852167	Martinez, Adriana 340B Program Manager Cook Children's Medical Center 6828852167	3/9/2018 1:15 PM
Contacts	Primary Contact	Update	Profile Change Request	Martinez, Adriana 340B Program Manager Cook Chidlrens Medical Center 6828852167	Martinez, Adriana 340B Program Manager Cook Childrens Medical Center 6828852167	3/9/2018 1:15 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	11/9/2017 10:28:43 AM	11/9/2017 10:28 AM
Contacts	Authorizing Official	Update		Cychol, Nancy President 6828854340	Cychol, Nancy President Cook Children's Medical Center 6828854340	10/19/2017 5:22 PM
Contacts	Primary Contact	Update	Profile Change Request	Martinez, Adriana 340B Program Manager Cook Chidlrens Medical Center 6828856935	Martinez, Adriana 340B Program Manager Cook Chidlrens Medical Center 6828852167	10/4/2017 11:01 AM
Contacts	Primary Contact	Update		Martinez, Adriana 340B Program Manager 6828856935	Martinez, Adriana 340B Program Manager Cook Chidlrens Medical Center 6828856935	10/4/2017 10:57 AM
Contacts	Authorizing Official	Insert			Cychol, Nancy President 6828854340	8/11/2017 11:56 AM
Contacts	Signed By	Insert			GOODE, RICHARD CHIEF FINANCIAL OFFICER 6828854000-7663	8/11/2017 11:56 AM
Contacts	Primary Contact	Update		Haley, Cindi 340B Program Manager 6828857127	Martinez, Adriana 340B Program Manager 6828856935	8/11/2017 11:56 AM
Addresses	Main Address	Insert			401 N. Valley Pkwy, Suite #400 Lewisville, TX 75067	8/10/2017 3:42 PM
Medicaid Billing	Medicaid: Number	Update		OK100702730A	100702730A	8/2/2017 2:39 PM
Contacts	Primary Contact	Insert			Haley, Cindi 340B Program Manager 6828857127	8/2/2017 2:39 PM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 11:43 AM
Details	Last Recertification Date	Update		9/8/2014 12:00:00 AM	8/31/2015 12:00:00 AM	8/31/2015 10:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/16/2015 3:06 PM
Medicaid Billing	Medicaid: Number	Insert			OK100702730A	1/16/2015 3:06 PM
Medicaid Billing	Medicaid: State	Insert			OK	1/16/2015 3:06 PM
Medicaid Billing	NPI: Number	Insert			1942509963	1/16/2015 3:06 PM
Details	Entity Subname	Update		Lewisville Psychology Clinic	Lewisville Specialty Clinic ~ Behavioral Health Clinic	1/16/2015 3:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/8/2014 3:14 PM
Medicaid Billing	Medicaid: Number	Insert			021184901	9/8/2014 3:14 PM
Medicaid Billing	Medicaid: State	Insert			TX	9/8/2014 3:14 PM
Medicaid Billing	NPI: Number	Insert			1891765178	9/8/2014 3:14 PM
Details	Last Recertification Date	Update			9/8/2014 12:00:00 AM	9/8/2014 3:14 PM
Dates	Participating Approval Date	Update			12/12/2013 12:00:00 AM	12/12/2013 4:20 PM
Details	State	Update		Pending	Active	12/12/2013 4:20 PM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	12/12/2013 4:20 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	PED453300-32	12/9/2013 1:25 PM
Details	Last Recertification Date	Insert				10/9/2013 5:53 PM
Details	Grant Number	Insert				10/9/2013 5:53 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/9/2013 5:53 PM
Details	Is Authorizing Official EHB Data	Insert				10/9/2013 5:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/9/2013 5:53 PM
Details	Medicare Provider Number	Insert			453300	10/9/2013 5:53 PM
Details	Entity Name	Insert			COOK CHILDREN'S MEDICAL CENTER	10/9/2013 5:53 PM
Details	Program Code	Insert			PED	10/9/2013 5:53 PM
Details	Entity Subname	Insert			Lewisville Psychology Clinic	10/9/2013 5:53 PM
Dates	Participating Approval Date	Insert				10/9/2013 5:53 PM
Details	State	Insert			Pending	10/9/2013 5:53 PM
Dates	Registration Date	Insert			10/9/2013 12:00:00 AM	10/9/2013 5:53 PM
Dates	Signed By Date	Insert			10/9/2013 12:00:00 AM	10/9/2013 5:53 PM
Dates	Start Date	Insert				10/9/2013 5:53 PM
Terminations	Termination Comments	Insert				10/9/2013 5:53 PM
Terminations	Termination Date	Insert				10/9/2013 5:53 PM
Terminations	Termination Effective Date	Insert				10/9/2013 5:53 PM
Terminations	Termination Reason	Insert				10/9/2013 5:53 PM