Covered Entity Details

PED453315-04 CHRISTUS Children's (Active) - information as of 5/9/2025 12:20:06 AM

Main Details

Name

CHRISTUS Children's

Subdivision Name

Specialty Care Center

Type

Children's Hospital

Rural

340B ID

PED453315-04

Medicare Provider Number

453315

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/17/2017

Participating Start Date

4/1/2017

Participating Approval Date

2/21/2017

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

CHRISTUS Santa Rosa
Steve Chen, CFO
(210) 321-8031

Primary Contact

CHRISTUS Santa Rosa Health System
Dustyn Tysdal, REGIONAL DIRECTOR OF PHARMACY
(210) 704-0130

Addresses

Street Address

15900 La Cantera Parkway
Suite 19240
San Antonio, TX 78256

Billing Address

CHRISTUS Children's
333 North Santa Rosa Street
San Antonio, TX 78207

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	020844904,020844903,020844902,020844906,091296603	1821004151

Shipping Addresses

Shipping Address 1

CHRISTUS Children's
333 North Santa Rosa Street
San Antonio, TX 78207

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
PED453315-01	Child	PED	Children's Hospital of San Antonio	Pediatric Multi-Specialty Center Westover Hills	11130 CHRISTUS Hills Medical Plaza 3, Suite 312D	San Antonio	TX	Terminated
PED453315-02	Child	PED	CHRISTUS Children's	Pediatric Multi-Specialty Center New Braunfels	598 N. Union Ave. STE 230	New Braunfels	TX	Active
PED453315-03	Child	PED	CHRISTUS Children's	Emergency Center	11130 CHRISTUS Hills, Suite 119	San Antonio	TX	Active
PED453315-04	Child	PED	CHRISTUS Children's	Specialty Care Center	15900 La Cantera Parkway	San Antonio	TX	Active
PED453315-05	Child	PED	CHRISTUS Children's	CHRISTUS Children's Emergency Center-Stone Oak - Free Standing Emergency Department	1434 Sonterra Blvd	San Antonio	TX	Active
PED453315-06	Child	PED	CHRISTUS Children's	Stone Oak Cardiology - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-07	Child	PED	CHRISTUS Children's	Stone Oak GI - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-08	Child	PED	CHRISTUS Children's	Stone Oak ED - MRI	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-09	Child	PED	CHRISTUS Children's	Stone Oak ENT - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-10	Child	PED	CHRISTUS Children's	Maternal Fetal Medicine Clinic - Clinic	315 N. San Saba	San Antonio	TX	Active
PED453315-11	Child	PED	CHRISTUS Children's	Stone Oak Orthopedics - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-12	Child	PED	CHRISTUS Children's	Alamo Ranch Clinic - Clinic	11345 Alamo Ranch Pkwy.	San Antonio	TX	Active
PED453315-13	Child	PED	CHRISTUS Children's	Stone Oak Nephrology - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-14	Child	PED	CHRISTUS Children's	Stone Oak Neurology - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-15	Child	PED	CHRISTUS Children's	Pedi Kidstop	11130 CHRISTUS HILLS	SAN ANTONIO	TX	Active
PED453315-16	Child	PED	CHRISTUS Children's	CHRISTUS Children's Multispecialty Clinic	5210 THOUSAND OAKS DR	SAN ANTONIO	TX	Active
PED453315-17	Child	PED	CHRISTUS Children's	CHRISTUS Children's Maternal Fetal Medicine - New Braunfels - Clinic	2115 STEPHENS PL	NEW BRAUNFELS	TX	Active
PED453315-18	Child	PED	CHRISTUS Children's	Stone Oak Respiratory Therapy - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-19	Child	PED	CHRISTUS Children's	Stone Oak HemOnc - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-20	Child	PED	CHRISTUS Children's	Stone Oak General Surgery - Clinic	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-21	Child	PED	CHRISTUS Children's	Stone Oak Clinic - Multi-Specialty	1434 E. Sonterra Blvd.	San Antonio	TX	Active
PED453315-22	Child	PED	CHRISTUS Children's	CHRISTUS CHILDREN'S - CHILDREN'S HOSPITAL OF SAN ANTONIO SOUTHSIDE MULTISPECIALTY CLINIC	7430 BARLITE BLVD	SAN ANTONIO	TX	Active
PED453315-23	Child	PED	CHRISTUS Children's	CHRISTUS Children's - MATERNAL FETAL MEDICINE	11212 State Highway 151	San Antonio	TX	Active
PED453315-24	Child	PED	CHRISTUS Children's	CHRISTUS Children's Multispecialty Clinic - Genetics	5210 THOUSAND OAKS DR	SAN ANTONIO	TX	Active
PED453315-25	Child	PED	CHRISTUS Children's	CHRISTUS Children's Multispecialty Clinic - Neurology	5210 THOUSAND OAKS DR	SAN ANTONIO	TX	Active
PED453315-26	Child	PED	CHRISTUS Children's	CHRISTUS CHILDREN'S - Stone Oak Genetics - Clinic	1434 E SONTERRA BLVD	SAN ANTONIO	TX	Active
PED453315-27	Child	PED	CHRISTUS Children's	CHRISTUS CHILDREN'S - Stone Oak Pulmonology - Clinic	1434 E SONTERRA BLVD	SAN ANTONIO	TX	Active
PED453315-28	Child	PED	CHRISTUS Children's	CHRISTUS CENTER FOR WOMEN'S HEALTH - Women's Health	315 N SAN SABA	SAN ANTONIO	TX	Active
PED453315-29	Child	PED	CHRISTUS Children's	CHRISTUS CHILDREN'S - Specialty Care Center - Psychiatric Therapy	15900 LA CANTERA PKWY	SAN ANTONIO	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Insert	Group Change Request		CHRISTUS Children's 333 North Santa Rosa Street San Antonio, TX 78207	1/14/2025 8:14 AM
Addresses	Shipping Address	Insert	Group Change Request		CHRISTUS Children's 333 North Santa Rosa Street San Antonio, TX 78207	1/14/2025 8:14 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 12:45:35 PM	8/15/2024 2:37:23 PM	8/15/2024 2:37 PM
Contacts	Primary Contact	Update	Profile Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107040130	Tysdal, Dustyn REGIONAL DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107040130	6/11/2024 3:05 PM
Contacts	Primary Contact	Update	Profile Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107042935	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107040130	6/11/2024 3:04 PM
Details	Last Recertification Date	Update	Recertification	9/14/2022 11:15:08 AM	8/15/2023 12:45:35 PM	8/15/2023 12:45 PM
Details	Entity Name	Update	Change Request	Children's Hospital of San Antonio	CHRISTUS Children's	7/20/2023 4:34 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 4:18:59 PM	9/14/2022 11:15:08 AM	9/14/2022 11:15 AM
Contacts	Authorizing Official	Update	AO Change Request	Parker, Stephanie VP Finance Christus Santa Rosa 2107043657	Chen, Steve CFO CHRISTUS Santa Rosa 2103218031	4/11/2022 10:33 AM
Contacts	Primary Contact	Update	Group Change Request	Younts, Stephanie Director of Pharmacy Childrens Hospital of San Antonio 2107042935	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107042935	11/18/2021 10:26 AM
Details	Last Recertification Date	Update	Recertification	9/3/2020 11:24:39 AM	8/17/2021 4:18:59 PM	8/17/2021 4:18 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	020844903 (TX)		9/3/2020 11:24 AM
Medicaid Billing	NPI: State	Update	Recertification		TX	9/3/2020 11:24 AM
Details	Last Recertification Date	Update	Recertification	8/31/2019 7:42:51 AM	9/3/2020 11:24:39 AM	9/3/2020 11:24 AM
Contacts	Authorizing Official	Update	AO Change Request	Kirks, Linda Regional VP/CFO The Children's Hospital of San Antonio 2107042624	Parker, Stephanie VP Finance Christus Santa Rosa 2107043657	1/7/2020 2:16 PM
Contacts	Primary Contact	Update	Change Request	Collins, Tina Interim Director of Pharmacy CHRISTUS Childrens Hospital of San Antonio 2107042935	Younts, Stephanie Director of Pharmacy Childrens Hospital of San Antonio 2107042935	11/14/2019 6:39 AM
Contacts	Primary Contact	Update	Recertification	Koger, Cynthia Director of Pharmacy The Children’s Hospital of San Antonio 2107042935	Collins, Tina Interim Director of Pharmacy CHRISTUS Childrens Hospital of San Antonio 2107042935	8/31/2019 7:42 AM
Details	Last Recertification Date	Update	Recertification	9/4/2018 11:34:04 AM	8/31/2019 7:42:51 AM	8/31/2019 7:42 AM
Details	Last Recertification Date	Update	Recertification	11/17/2017 9:40:09 AM	9/4/2018 11:34:04 AM	9/4/2018 11:34 AM
Details	Last Recertification Date	Update	Recertification		11/17/2017 9:40:09 AM	11/17/2017 9:40 AM
Details	Entity Name	Update	Recertification	CHILDRENS HOSPITAL OF SAN ANTONIO	Children's Hospital of San Antonio	11/17/2017 9:34 AM
Contacts	Primary Contact	Update	Recertification	Koger, Cynthia CHofSA Pharmacy Director 2107042935	Koger, Cynthia Director of Pharmacy The Children’s Hospital of San Antonio 2107042935	11/17/2017 9:32 AM
Contacts	Authorizing Official	Update		Kirks, Linda Regional VP/CFO 2107042624	Kirks, Linda Regional VP/CFO The Children's Hospital of San Antonio 2107042624	10/9/2017 3:50 PM
Contacts	Signed By	Update		Kirks, Linda Regional VP/CFO 2107042624	Kirks, Linda Regional VP/CFO The Children's Hospital of San Antonio 2107042624	10/9/2017 3:50 PM
Contacts	Authorizing Official	Insert			Kirks, Linda Regional VP/CFO 2107042624	7/25/2017 10:25 AM
Contacts	Signed By	Insert			Kirks, Linda Regional VP/CFO 2107042624	7/25/2017 10:25 AM
Contacts	Primary Contact	Insert			Koger, Cynthia CHofSA Pharmacy Director 2107042935	2/21/2017 1:32 PM
Addresses	Main Address	Insert			15900 La Cantera Parkway Suite 19240 San Antonio, TX 78256	2/21/2017 1:32 PM
Dates	Participating Approval Date	Update			2/21/2017 12:00:00 AM	2/21/2017 1:32 PM
Details	State	Update		Pending	Active	2/21/2017 1:32 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	2/21/2017 1:32 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_75212	PED453315-04	2/15/2017 12:53 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_75212	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			020844904	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: State	Insert			TX	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			020844903	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: State	Insert			TX	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			020844903	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: State	Insert			TX	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			020844902	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: State	Insert			TX	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			020844906	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: State	Insert			TX	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			091296603	1/17/2017 11:55 AM
Medicaid Billing	Medicaid: State	Insert			TX	1/17/2017 11:55 AM
Medicaid Billing	NPI: Number	Insert			1821004151	1/17/2017 11:55 AM
Details	Last Recertification Date	Insert				1/17/2017 11:55 AM
Details	Grant Number	Insert				1/17/2017 11:55 AM
Details	340B ID	Insert				1/17/2017 11:55 AM
Details	Is Authorizing Official EHB Data	Insert				1/17/2017 11:55 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/17/2017 11:55 AM
Details	Medicare Provider Number	Insert			453315	1/17/2017 11:55 AM
Details	Entity Name	Insert			CHILDRENS HOSPITAL OF SAN ANTONIO	1/17/2017 11:55 AM
Details	Program Code	Insert			PED	1/17/2017 11:55 AM
Details	Entity Subname	Insert			Specialty Care Center	1/17/2017 11:55 AM
Dates	Participating Approval Date	Insert				1/17/2017 11:55 AM
Details	State	Insert			Pending	1/17/2017 11:55 AM
Dates	Registration Date	Insert			1/17/2017 12:00:00 AM	1/17/2017 11:55 AM
Dates	Signed By Date	Insert			1/17/2017 12:00:00 AM	1/17/2017 11:55 AM
Dates	Start Date	Insert				1/17/2017 11:55 AM
Terminations	Termination Comments	Insert				1/17/2017 11:55 AM
Terminations	Termination Date	Insert				1/17/2017 11:55 AM
Terminations	Termination Effective Date	Insert				1/17/2017 11:55 AM
Terminations	Termination Reason	Insert				1/17/2017 11:55 AM