| Addresses | Shipping Address | Insert | Change Request | | Houston Methodist Willowbrook Hospital
18220 State HWY 249
Houston, TX 77070 | 4/14/2025 10:25 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2023 8:59:15 AM | 8/15/2024 12:17:01 PM | 8/15/2024 12:17 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 140732201 (TX) | | 1/15/2024 2:15 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 140713201 (TX) | | 1/15/2024 2:15 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 10:37:51 AM | 8/30/2023 8:59:15 AM | 8/30/2023 8:59 AM |
| Contacts | Authorizing Official | Update | Change Request | Twine, Nicole
Vice President / CNO
Houston Methodist Willowbrook Hospital
2813876505 | Peterson, Julie K
Vice President/Chief Operating Officer
Houston Methodist Willowbrook Hospital
2817372115 | 2/7/2023 4:06 PM |
| Addresses | Main Address | Update | Change Request |
18220 TOMBALL PARKWAY (Hwy 249)
HOUSTON, TX 77070 |
18220 STATE HIGHWAY 249
HOUSTON, TX 77070-4347 | 10/18/2022 11:22 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 9:48:54 AM | 9/8/2022 10:37:51 AM | 9/8/2022 10:37 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Fontenette, Makiltru L
ACNO
Houston Methodist Willowbrook
2817570976 | Twine, Nicole
Vice President / CNO
Houston Methodist Willowbrook Hospital
2813876505 | 8/30/2022 2:28 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 7/11/2022 10:11 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 140732201 | 7/11/2022 10:11 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | TX | 7/11/2022 10:11 AM |
| Details | Last Recertification Date | Update | Recertification | 9/14/2020 10:29:36 AM | 8/27/2021 9:48:54 AM | 8/27/2021 9:48 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1871619254 ( ) | | 9/14/2020 10:29 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1871619254 | 9/14/2020 10:29 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | TX | 9/14/2020 10:29 AM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2019 7:57:56 PM | 9/14/2020 10:29:36 AM | 9/14/2020 10:29 AM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2018 11:28:52 AM | 9/2/2019 7:57:56 PM | 9/2/2019 7:57 PM |
| Details | Entity Name | Update | Change Request | METHODIST WILLOWBROOK HOSPITAL | HOUSTON METHODIST WILLOWBROOK HOSPITAL | 5/9/2019 9:39 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/23/2018 11:28:52 AM | 8/23/2018 11:28 AM |
| Contacts | Authorizing Official | Update | Change Request | Dennis, Glenn I
Associate Chief of Nursing
Houston Methodist Willowbrook Hospital
2817371028 | Fontenette, Makiltru L
ACNO
Houston Methodist Willowbrook
2817570976 | 7/30/2018 8:12 AM |
| Terminations | Termination Reason | Update | | Site closure | | 7/21/2018 12:21 PM |
| Contacts | Authorizing Official | Update | Change Request | Barber, Keith D
SVP / CEO
Houston Methodist Willowbrook
2817371003 | Dennis, Glenn I
Associate Chief of Nursing
Houston Methodist Willowbrook Hospital
2817371028 | 3/28/2018 4:02 PM |
| Details | State | Update | Change Request | Approved | Active | 3/28/2018 4:02 PM |
| Addresses | Main Address | Update | Change Request |
18220 TOMBALL PARKWAY HOSPITAL
HOUSTON, TX 77070 |
18220 TOMBALL PARKWAY (Hwy 249)
HOUSTON, TX 77070 | 3/15/2018 11:23 AM |
| Contacts | Authorizing Official | Update | Reinstatement | Tyrrell, Edward L.
Sr. Vice President - Corporate Finance
8326676074 | Barber, Keith D
SVP / CEO
Houston Methodist Willowbrook
2817371003 | 2/2/2018 2:16 PM |
| Contacts | Signed By | Update | Reinstatement | Tyrrell, Edward L.
Sr. Vice President - Corporate Finance
8326676074 | Barber, Keith D
SVP / CEO
Houston Methodist Willowbrook
2817371003 | 2/2/2018 2:16 PM |
| Dates | Participating Approval Date | Update | Reinstatement | | 2/2/2018 2:16:39 PM | 2/2/2018 2:16 PM |
| Details | State | Update | Reinstatement | Pending | Approved | 2/2/2018 2:16 PM |
| Dates | Signed By Date | Update | Reinstatement | 8/5/2015 12:00:00 AM | 1/4/2018 6:10:59 PM | 2/2/2018 2:16 PM |
| Dates | Start Date | Update | Reinstatement | | 4/1/2018 12:00:00 AM | 2/2/2018 2:16 PM |
| Terminations | Termination Reason | Update | Reinstatement | | Site closure | 2/2/2018 2:16 PM |
| Details | Comments Public | Insert | Reinstatement | | Participated starting 10/1/2015, terminated 10/1/2015. Reinstated 4/1/2018. | 1/26/2018 1:52 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 9/24/2015 12:00:00 AM | | 1/4/2018 11:37 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 8/19/2015 12:00:00 AM | | 1/4/2018 11:37 AM |
| Details | State | Update | Reinstatement | Terminated | Pending | 1/4/2018 11:37 AM |
| Dates | Registration Date | Update | Reinstatement | 8/5/2015 12:00:00 AM | 1/4/2018 11:37:55 AM | 1/4/2018 11:37 AM |
| Dates | Start Date | Update | Reinstatement | 10/1/2015 12:00:00 AM | | 1/4/2018 11:37 AM |
| Terminations | Termination Comments | Update | Reinstatement | HMWB registered for the first time during the July 1st, 2015 open enrollment period. Starting this coming October 1st, 2015 HMWB will be eligible to participate in the 340B program. At this point in time, we have not successfully implemented a split billing program to facilitate managing the inventory and ensure we are not violating the GPO prohibition starting October 1st. We’ve entertained the option of managing the process manually but there is a significant amount of mix use putting us a | | 1/4/2018 11:37 AM |
| Terminations | Termination Date | Update | Reinstatement | 10/1/2015 12:00:00 AM | | 1/4/2018 11:37 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 9/24/2015 12:00:00 AM | | 1/4/2018 11:37 AM |
| Terminations | Termination Reason | Update | Reinstatement | Site closure | | 1/4/2018 11:37 AM |
| Contacts | Primary Contact | Update | | Metzen, Daniel
System Director of Pharmacy
7134412141 | Metzen, Daniel
System Director of Pharmacy
Houston Methodist
7134412141 | 10/13/2017 9:16 AM |
| Contacts | Primary Contact | Insert | | | Metzen, Daniel
System Director of Pharmacy
7134412141 | 9/1/2016 9:14 AM |
| Contacts | Authorizing Official | Insert | | | Tyrrell, Edward L.
Sr. Vice President - Corporate Finance
8326676074 | 9/25/2015 9:16 AM |
| Contacts | Signed By | Insert | | | Tyrrell, Edward L.
Sr. Vice President - Corporate Finance
8326676074 | 9/25/2015 9:16 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 9/24/2015 12:00:00 AM | 9/25/2015 9:15 AM |
| Details | State | Update | | Active | Terminated | 9/25/2015 9:15 AM |
| Terminations | Termination Comments | Update | | | HMWB registered for the first time during the July 1st, 2015 open enrollment period. Starting this coming October 1st, 2015 HMWB will be eligible to participate in the 340B program. At this point in time, we have not successfully implemented a split billing program to facilitate managing the inventory and ensure we are not violating the GPO prohibition starting October 1st. We’ve entertained the option of managing the process manually but there is a significant amount of mix use putting us a | 9/25/2015 9:15 AM |
| Terminations | Termination Date | Update | | | 10/1/2015 12:00:00 AM | 9/25/2015 9:15 AM |
| Terminations | Termination Effective Date | Update | | | 9/24/2015 12:00:00 AM | 9/25/2015 9:15 AM |
| Terminations | Termination Reason | Update | | | Site closure | 9/25/2015 9:15 AM |
| Addresses | Main Address | Insert | | |
18220 TOMBALL PARKWAY HOSPITAL
HOUSTON, TX 77070 | 9/25/2015 9:15 AM |
| Dates | Participating Approval Date | Update | | | 8/19/2015 12:00:00 AM | 8/19/2015 1:58 PM |
| Details | State | Update | | Pending | Active | 8/19/2015 1:58 PM |
| Dates | Start Date | Update | | | 10/1/2015 12:00:00 AM | 8/19/2015 1:58 PM |
| Details | Medicare Provider Number | Update | | 000000 | 450844 | 8/17/2015 5:27 PM |
| Details | Medicare Provider Number | Update | | 450844 | 000000 | 8/13/2015 11:06 AM |
| Details | 340B ID | Update | | ONLINE_REG_54087 | DSH450844 | 8/6/2015 5:37 PM |
| Details | 340B ID | Update | | | ONLINE_REG_54087 | 8/5/2015 3:55 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 8/5/2015 3:55 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 140713201 | 8/5/2015 3:55 PM |
| Medicaid Billing | Medicaid: State | Insert | | | TX | 8/5/2015 3:55 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1871619254 | 8/5/2015 3:55 PM |
| Details | Last Recertification Date | Insert | | | | 8/5/2015 3:55 PM |
| Details | Grant Number | Insert | | | | 8/5/2015 3:55 PM |
| Details | 340B ID | Insert | | | | 8/5/2015 3:55 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 8/5/2015 3:55 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 8/5/2015 3:55 PM |
| Details | Medicare Provider Number | Insert | | | 450844 | 8/5/2015 3:55 PM |
| Details | Entity Name | Insert | | | METHODIST WILLOWBROOK HOSPITAL | 8/5/2015 3:55 PM |
| Details | Program Code | Insert | | | DSH | 8/5/2015 3:55 PM |
| Details | Entity Subname | Insert | | | | 8/5/2015 3:55 PM |
| Dates | Participating Approval Date | Insert | | | | 8/5/2015 3:55 PM |
| Details | State | Insert | | | Pending | 8/5/2015 3:55 PM |
| Dates | Registration Date | Insert | | | 8/5/2015 12:00:00 AM | 8/5/2015 3:55 PM |
| Dates | Signed By Date | Insert | | | 8/5/2015 12:00:00 AM | 8/5/2015 3:55 PM |
| Dates | Start Date | Insert | | | | 8/5/2015 3:55 PM |
| Terminations | Termination Comments | Insert | | | | 8/5/2015 3:55 PM |
| Terminations | Termination Date | Insert | | | | 8/5/2015 3:55 PM |
| Terminations | Termination Effective Date | Insert | | | | 8/5/2015 3:55 PM |
| Terminations | Termination Reason | Insert | | | | 8/5/2015 3:55 PM |