| Details | Last Recertification Date | Update | Recertification | 9/5/2023 2:13:57 PM | 8/29/2024 3:45:56 PM | 8/29/2024 3:45 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Wucki, Eric John
340B Manager
Memorial Hermann
2625272475 | Wucki, Eric John
Director of Pharmacy-340B
Memorial Hermann
2625272475 | 8/5/2024 1:13 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2022 2:41:34 PM | 9/5/2023 2:13:57 PM | 9/5/2023 2:13 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2021 12:43:43 PM | 9/7/2022 2:41:34 PM | 9/7/2022 2:41 PM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2020 7:58:56 PM | 8/30/2021 12:43:43 PM | 8/30/2021 12:43 PM |
| Contacts | Primary Contact | Update | Change Request | Rangel, Illiana
340B Manager
Memorial Hermann
7132422858 | Wucki, Eric John
340B Manager
Memorial Hermann
2625272475 | 4/18/2021 2:33 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Tucker, Rebecca
VP, Finance
Memorial Hermann System
7134565340 | Ogden, Robert C
Associate Vice President of Finance
Memorial Hermann
7134565111 | 11/16/2020 4:13 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1295788735 | 9/11/2020 7:58 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | TX | 9/11/2020 7:58 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1295788735 ( ) | | 9/11/2020 7:58 PM |
| Details | Last Recertification Date | Update | Recertification | 9/13/2019 9:48:46 AM | 9/11/2020 7:58:56 PM | 9/11/2020 7:58 PM |
| Addresses | Billing Address | Update | Recertification | Memorial Hermann Sugar Land
17500 West Grand Parkway South
Sugar Land, TX 77479 | Memorial Hermann
929 Gessner Rd, Suite 2690
Houston, TX 77024 | 9/13/2019 9:48 AM |
| Addresses | Shipping Address | Delete | Recertification | Memorial Hermann Sugar Land
17500 West Grand Parkway South
Sugar Land, TX 77479 | | 9/13/2019 9:48 AM |
| Addresses | Shipping Address | Insert | Recertification | | Memorial Hermann Sugar Land
17500 West Grand Parkway
Sugar Land, TX 77479 | 9/13/2019 9:48 AM |
| Addresses | Main Address | Update | Recertification |
8780 Highway 6
Missouri City, TX 77459 |
8780 Highway 6, Suite B
Missouri City, TX 77459 | 9/13/2019 9:48 AM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2018 8:46:03 PM | 9/13/2019 9:48:46 AM | 9/13/2019 9:48 AM |
| Contacts | Primary Contact | Update | Change Request | Maack, Jo Ann
System Pharmacy Director
Memorial Hermann System
7132422814 | Rangel, Illiana
340B Manager
Memorial Hermann
7132422858 | 8/1/2019 6:55 AM |
| Details | Last Recertification Date | Update | Recertification | 11/30/2017 4:23:43 PM | 9/11/2018 8:46:03 PM | 9/11/2018 8:46 PM |
| Addresses | Billing Address | Insert | Recertification | | Memorial Hermann Sugar Land
17500 West Grand Parkway South
Sugar Land, TX 77479 | 11/30/2017 4:23 PM |
| Addresses | Shipping Address | Insert | Recertification | | Memorial Hermann Sugar Land
17500 West Grand Parkway South
Sugar Land, TX 77479 | 11/30/2017 4:23 PM |
| Details | Last Recertification Date | Update | Recertification | | 11/30/2017 4:23:43 PM | 11/30/2017 4:23 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Tucker, Rebecca
CFO
Memorial Hermann System
7134565340 | Tucker, Rebecca
VP, Finance
Memorial Hermann System
7134565340 | 11/21/2017 10:54 AM |
| Contacts | Primary Contact | Insert | Change Request | | Maack, Jo Ann
System Pharmacy Director
Memorial Hermann System
7132422814 | 10/3/2017 11:17 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Tucker, Rebecca
CFO
Memorial Hermann System
2815407802 | Tucker, Rebecca
CFO
Memorial Hermann System
7134565340 | 9/29/2017 3:01 PM |
| Details | Entity Name | Update | Change Request | MEMORIAL HERMANN SUGAR LAND HOSPITAL | Memorial Hermann Sugar Land Hospital | 9/29/2017 2:39 PM |
| Contacts | Authorizing Official | Update | | Tucker, Rebecca
CFO
2815407802 | Tucker, Rebecca
CFO
Memorial Hermann System
2815407802 | 9/29/2017 1:44 PM |
| Contacts | Signed By | Insert | | | Yeung, Daisy
CFO
2817255217 | 8/11/2017 1:03 PM |
| Contacts | Authorizing Official | Insert | | | Tucker, Rebecca
CFO
2815407802 | 8/10/2017 2:26 PM |
| Addresses | Main Address | Insert | | |
8780 Highway 6
Missouri City, TX 77459 | 2/19/2017 8:53 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1295788735 | 2/19/2017 8:53 PM |
| Dates | Participating Approval Date | Update | | | 11/2/2016 12:00:00 AM | 11/2/2016 3:39 PM |
| Details | State | Update | | Pending | Active | 11/2/2016 3:39 PM |
| Dates | Start Date | Update | | | 1/1/2017 12:00:00 AM | 11/2/2016 3:39 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_73206 | DSH450848P | 11/2/2016 8:34 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_73206 | 10/14/2016 11:40 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/14/2016 11:40 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 146021401 | 10/14/2016 11:40 AM |
| Medicaid Billing | Medicaid: State | Insert | | | TX | 10/14/2016 11:40 AM |
| Details | Last Recertification Date | Insert | | | | 10/14/2016 11:40 AM |
| Details | Grant Number | Insert | | | | 10/14/2016 11:40 AM |
| Details | 340B ID | Insert | | | | 10/14/2016 11:40 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/14/2016 11:40 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/14/2016 11:40 AM |
| Details | Medicare Provider Number | Insert | | | 450848 | 10/14/2016 11:40 AM |
| Details | Entity Name | Insert | | | MEMORIAL HERMANN SUGAR LAND HOSPITAL | 10/14/2016 11:40 AM |
| Details | Program Code | Insert | | | DSH | 10/14/2016 11:40 AM |
| Details | Entity Subname | Insert | | | Sienna Convenient Care Center | 10/14/2016 11:40 AM |
| Dates | Participating Approval Date | Insert | | | | 10/14/2016 11:40 AM |
| Details | State | Insert | | | Pending | 10/14/2016 11:40 AM |
| Dates | Registration Date | Insert | | | 10/14/2016 12:00:00 AM | 10/14/2016 11:40 AM |
| Dates | Signed By Date | Insert | | | 10/14/2016 12:00:00 AM | 10/14/2016 11:40 AM |
| Dates | Start Date | Insert | | | | 10/14/2016 11:40 AM |
| Terminations | Termination Comments | Insert | | | | 10/14/2016 11:40 AM |
| Terminations | Termination Date | Insert | | | | 10/14/2016 11:40 AM |
| Terminations | Termination Effective Date | Insert | | | | 10/14/2016 11:40 AM |
| Terminations | Termination Reason | Insert | | | | 10/14/2016 11:40 AM |