Covered Entity Details

DSH440049FD METHODIST HEALTHCARE - MEMPHIS HOSPITALS (Active) - information as of 5/8/2025 10:25:23 PM

Main Details

Name

METHODIST HEALTHCARE - MEMPHIS HOSPITALS

Subdivision Name

Methodist Medical Group - Haque

Type

Disproportionate Share Hospital

Rural

340B ID

DSH440049FD

Medicare Provider Number

440049

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/6/2017

Participating Start Date

7/1/2017

Participating Approval Date

5/1/2017

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Methodist Healthcare - Memphis Hospitals
Chuck Lane, SVP/Associate CFO
(901) 516-0549

Primary Contact

Methodist Le Bonheur Healthcare
Chris Hilty, Director - Pharmacy Supply Chain
(901) 516-7570

Addresses

Street Address

6401 Poplar Ave
Ste 530
Memphis, TN 38119

Billing Address

Methodist Healthcare - Memphis Hospitals
P.O. Box 41058
Memphis, TN 38104

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
TN	6045088,3018431,0009485,620479367,0440049	1558365890
AR	107115105	1558365890
MS	00020469,620479367	1558365890

Shipping Addresses

Shipping Address 1

Methodist Healthcare Univ. Department of Pharmacy
1265 Union Ave
Memphis, TN 38104

Shipping Address 2

Methodist Medical Group
6401 Poplar Ave
Ste 530
Memphis, TN 38119

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
DSH440049AA	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Dialysis - Acute	3960 New Covington Pike	Memphis	TN	Active
DSH440049AB	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Same Day Surgery	3960 New Covington Pike	Memphis	TN	Active
DSH440049AC	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Emergency Department	3960 New Covington Pike	Memphis	TN	Active
DSH440049AD	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Clinical Decision Unit	3960 New Covington Pike	Memphis	TN	Active
DSH440049AE	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Cardiovascular Services	3960 New Covington Pike	Memphis	TN	Active
DSH440049AF	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Catheterization Lab	3960 New Covington Pike	Memphis	TN	Active
DSH440049AG	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Radiology - Diagnostic	3960 New Covington Pike	Memphis	TN	Active
DSH440049AH	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Radiology - CT Scan	3960 New Covington Pike	Memphis	TN	Active
DSH440049AJ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - MRI	3960 New Covington Pike	Memphis	TN	Active
DSH440049AK	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Nuclear Medicine	3960 New Covington Pike	Memphis	TN	Active
DSH440049AL	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Physical Therapy	3960 New Covington Pike	Memphis	TN	Active
DSH440049AM	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Advanced Wound Care Center	3950 New Covington Pike, Suite 350	Memphis	TN	Active
DSH440049AN	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Emergency Department	848 Adams Ave	Memphis	TN	Active
DSH440049AP	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Catheterization Lab	848 Adams Ave	Memphis	TN	Active
DSH440049AQ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Nuclear Medicine	848 Adams Ave	Memphis	TN	Active
DSH440049AR	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Radiology - CT Scan	848 Adams Ave	Memphis	TN	Active
DSH440049AS	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - GI Lab	848 Adams Ave	Memphis	TN	Active
DSH440049AT	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Surgery - Operating Room	848 Adams Ave	Memphis	TN	Active
DSH440049AU	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Neuro Diagnostics	848 Adams Ave	Memphis	TN	Active
DSH440049AV	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Southwind Medical Specialists	3725 Champion Hills Dr	Memphis	TN	Active
DSH440049AW	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - MEG	848 Adams Ave	Memphis	TN	Active
DSH440049AX	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - MRI / MRA	848 Adams Ave	Memphis	TN	Active
DSH440049AY	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Cardiovascular Services	848 Adams Ave	Memphis	TN	Active
DSH440049AZ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Pulmonary Diagnostics	848 Adams Ave	Memphis	TN	Active
DSH440049BA	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Radiology - Diagnostic	848 Adams Ave	Memphis	TN	Active
DSH440049BB	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - PACU / Recovery Room Services	848 Adams Ave	Memphis	TN	Active
DSH440049BC	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Same Day Surgery	848 Adams Ave	Memphis	TN	Active
DSH440049BD	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Labor and Delivery	7691 Poplar Ave	Germantown	TN	Active
DSH440049BE	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Dialysis - Acute	7691 Poplar Ave	Germantown	TN	Active
DSH440049BF	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Respiratory Therapy	7691 Poplar Ave	Germantown	TN	Active
DSH440049BG	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Operating Room Services	7691 Poplar Ave	Germantown	TN	Active
DSH440049BH	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Same Day Surgery	7691 Poplar Ave	Germantown	TN	Active
DSH440049BJ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Recovery Room Services	7691 Poplar Ave	Germantown	TN	Active
DSH440049BK	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Emergency Room	7691 Poplar Ave	Germantown	TN	Active
DSH440049BL	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Lab Services	7691 Poplar Ave	Germantown	TN	Active
DSH440049BM	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Blood Bank	7691 Poplar Ave	Germantown	TN	Active
DSH440049BN	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Physiology GI	7691 Poplar Ave	Germantown	TN	Active
DSH440049BP	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Cardiovascular Services	7691 Poplar Ave	Germantown	TN	Active
DSH440049BQ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Cardiac Cath Lab	7691 Poplar Ave	Germantown	TN	Active
DSH440049BR	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - EEG	7691 Poplar Ave	Germantown	TN	Active
DSH440049BS	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - OP Cardiac Rehab	7691 Poplar Ave	Germantown	TN	Active
DSH440049BT	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Neurodiagnostics	7691 Poplar Ave	Germantown	TN	Active
DSH440049BU	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Pelvic Rehab	7691 Poplar Ave	Germantown	TN	Active
DSH440049BV	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Radiology - Diagnostic	7691 Poplar Ave	Germantown	TN	Active
DSH440049BW	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Radiology - Ultrasound	7691 Poplar Ave	Germantown	TN	Active
DSH440049BX	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Radiology - CT Scan	7691 Poplar Ave	Germantown	TN	Active
DSH440049BY	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Radiology - Special Procedures	7691 Poplar Ave	Germantown	TN	Active
DSH440049BZ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - MRI	7691 Poplar Ave	Germantown	TN	Active
DSH440049CA	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Nuclear Medicine	7691 Poplar Ave	Germantown	TN	Active
DSH440049CB	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Anesthesia	7691 Poplar Ave	Germantown	TN	Active
DSH440049CC	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Physical Therapy	7691 Poplar Ave	Germantown	TN	Active
DSH440049CD	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Occupational Therapy	7691 Poplar Ave	Germantown	TN	Active
DSH440049CE	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Speech Therapy	7691 Poplar Ave	Germantown	TN	Active
DSH440049CF	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Pediatric Rehab Services	7691 Poplar Ave	Germantown	TN	Active
DSH440049CG	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Outpatient Diagnostic Center - Ambulatory Care Clinics	51 N Dunlap St	Memphis	TN	Active
DSH440049CH	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Outpatient Diagnostic Center - Pediatric Rehab Services	51 N Dunlap St	Memphis	TN	Active
DSH440049CJ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Outpatient Diagnostic Center - Audiology Clinic	51 N Dunlap St	Memphis	TN	Active
DSH440049CK	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Outpatient Diagnostic Center - Radiology - Ultrasound	51 N Dunlap St	Memphis	TN	Active
DSH440049CL	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Outpatient Diagnostic Center - Urodynamics Lab	51 N Dunlap St	Memphis	TN	Active
DSH440049CM	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Outpatient Diagnostic Center - X-Ray Diagnostic	51 N Dunlap St	Memphis	TN	Active
DSH440049CN	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Research Center - Dialysis Unit	50 N Dunlap St	Memphis	TN	Active
DSH440049CP	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Research Center - Pediatric Clinical Research (DTU)	50 N Dunlap St	Memphis	TN	Active
DSH440049CQ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Research Center - Sleep Disorder Clinic	50 N Dunlap St	Memphis	TN	Active
DSH440049CR	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Healthcare Oncology Clinic - Wolf River - Oncology Infusion	7945 Wolf River Blvd	Germantown	TN	Terminated
DSH440049CS	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Healthcare Oncology Clinic - Wolf River - Radiology	7945 Wolf River Blvd	Germantown	TN	Terminated
DSH440049CT	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Healthcare Oncology Clinic - Wolf River - CT / MRI	7945 Wolf River Blvd	Germantown	TN	Terminated
DSH440049CU	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Diagnostic Center - Germantown	1377 S Germantown Rd	Germantown	TN	Active
DSH440049CV	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Diagnostic Center	1801 Union Ave	Memphis	TN	Active
DSH440049CW	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Healthcare Memphis Hospital - Methodist Sickle Cell Center	1265 Union Ave	Memphis	TN	Active
DSH440049CX	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Breast Diagnostic Center - Germantown	7945 Wolf River Blvd	Germantown	TN	Terminated
DSH440049CY	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist University Specialty Clinic	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049CZ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital Emergency Room Services - Urgent Care	848 Adams Ave	Memphis	TN	Active
DSH440049DA	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Lab Services	1300 Wesley Dr	Memphis	TN	Active
DSH440049DB	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Respiratory Therapy	3960 New Covington Pike	Memphis	TN	Active
DSH440049DC	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Lab Services	3960 New Covington Pike	Memphis	TN	Active
DSH440049DD	Child	DSH	METHODIST H/C MEMPHIS HOSPT.	Methodist Healthcare Oncology Clinic	1500 W Poplar Ave	Collierville	TN	Terminated
DSH440049DE	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Pavilion Surgery	7691 Poplar Ave	Germantown	TN	Active
DSH440049DF	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Angiography	3960 New Covington Pike	Memphis	TN	Active
DSH440049DG	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Pediatric Unit	7691 Poplar Ave	Germantown	TN	Active
DSH440049DH	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital - Gyn/Med Surg	7691 Poplar Ave	Germantown	TN	Active
DSH440049DJ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Children's Hospital - Germantown ED	7691 Poplar Avenue	Germantown	TN	Active
DSH440049DK	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Le Bonheur Germantown Hospital- Observation Unit	7691 Poplar Avenue	Germantown	TN	Active
DSH440049DL	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital- Observation Unit	3960 New Covington Pike	Memphis	TN	Active
DSH440049DM	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	METHODIST HEALTHCARE - MEMPHIS HOSP - Emergency Department	8071 WINCHESTER ROAD SUITE 2	MEMPHIS	TN	Active
DSH440049DN	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Outpatient Cardiovascular Diagnostic Center - Sutherland	7460 Wolf River Blvd	Germantown	TN	Active
DSH440049DP	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Healthcare Oncology Clinic West - Union	1211 Union Ave	Memphis	TN	Terminated
DSH440049DQ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Healthcare Oncology Clinic West - Collierville	1936 W Poplar Ave	Collierville	TN	Terminated
DSH440049DR	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Bone Marrow Transplant	1265 Union Ave	Memphis	TN	Active
DSH440049DS	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - South / Gastroenterology	1251 Wesley Dr	Memphis	TN	Active
DSH440049DT	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - South / Endocrinology	1251 Wesley Dr	Memphis	TN	Active
DSH440049DU	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Midtown / Pulmonary	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049DV	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Midtown / Neurology	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049DW	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Midtown / Infectious Disease	1211 Union Ave	Memphis	TN	Active
DSH440049DX	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Midtown / General Surgery	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049DY	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Midtown / Gastroenterology	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049DZ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Midtown / Endocrinology	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049E	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Oncology	1588 Union Ave	Memphis	TN	Terminated
DSH440049EA	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Wolf River / Thoracic Surgeons	7705 Poplar Ave	Germantown	TN	Active
DSH440049EB	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Wolf River / Surgical Oncology	7705 Poplar Ave	Germantown	TN	Active
DSH440049EC	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Wolf River / Otolaryngology	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049ED	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Surgical Oncology / Thoracic Surgeons	1265 Union Ave	Memphis	TN	Active
DSH440049EE	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Surgical Oncology / Surgical Oncology	1265 Union Ave	Memphis	TN	Active
DSH440049EF	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Cordova / Internal Medicine	57 Germantown Ct	Cordova	TN	Active
DSH440049EG	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Cordova / Infectious Disease	57 Germantown Ct	Cordova	TN	Active
DSH440049EH	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Cordova / Gastroenterology	57 Germantown Ct	Cordova	TN	Active
DSH440049EJ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Multi-Disciplinary Clinic - Cordova / Endocrinology	57 Germantown Ct	Cordova	TN	Active
DSH440049EK	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Sutherland Cardiology - South	1251 Wesley Dr	Memphis	TN	Active
DSH440049EL	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Sutherland Cardiology - MPB	1211 Union Ave	Memphis	TN	Active
DSH440049EM	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Sutherland Cardiology - North	3950 New Covington Pike	Memphis	TN	Active
DSH440049EN	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Sutherland Cardiology - Germantown	7460 Wolf River Blvd	Germantown	TN	Active
DSH440049EP	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Slade	3950 New Covington Pike	Memphis	TN	Active
DSH440049EQ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Southwind Sanderlin	5182 Sanderlin Ave	Memphis	TN	Active
DSH440049ER	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Southwind Medical Specialists - GI	3725 Champion Hills Dr	Memphis	TN	Active
DSH440049ES	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Southwind Champion Hills	3725 Champion Hills Dr	Memphis	TN	Active
DSH440049ET	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - PennMarc	6401 Poplar Ave	Memphis	TN	Terminated
DSH440049EU	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Peabody	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049EV	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Motley	1264 Wesley Dr	Memphis	TN	Active
DSH440049EW	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group Midtown	1533 Union Ave	Memphis	TN	Active
DSH440049EX	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - MFM Stone Creek	9047 Poplar Ave	Germantown	TN	Active
DSH440049EY	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - MFM Cordova	8115 Country Village Dr	Cordova	TN	Active
DSH440049EZ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - MFM Bartlett	2589 Appling Rd	Bartlett	TN	Active
DSH440049FA	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Lakeland	2961 Canada Rd	Lakeland	TN	Active
DSH440049FB	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Kraus	7550 Wolf River Blvd	Germantown	TN	Active
DSH440049FC	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Highland	3473 Poplar Ave	Memphis	TN	Active
DSH440049FD	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Haque	6401 Poplar Ave	Memphis	TN	Active
DSH440049FE	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Foundation	7690 Wolf River Cir	Germantown	TN	Active
DSH440049FF	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Endocrinology	6401 Poplar Ave	Memphis	TN	Active
DSH440049FG	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Eastmoreland	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049FH	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Covington Pike	3789 Covington Pike	Memphis	TN	Active
DSH440049FJ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Comprehensive	76 Capital Way	Atoka	TN	Active
DSH440049FK	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Brighton	1880 Old Hwy 51 S	Brighton	TN	Active
DSH440049FL	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Bartlett	6570 Summer Oaks Cv	Bartlett	TN	Active
DSH440049FM	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Arthritis Group	1211 Union Ave	Memphis	TN	Active
DSH440049FN	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Outpatient Center East / Rehab	100 N Humphreys Blvd	Memphis	TN	Active
DSH440049FP	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Outpatient Center East / Radiology	100 N Humphreys Blvd	Memphis	TN	Active
DSH440049FQ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Le Bonheur Research Center - East - Pediatric Clinical Research (DTU)	100 N Humphreys Blvd	Memphis	TN	Active
DSH440049FR	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP OTOLARNGOLOGY - Head and Neck Surgery	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049FS	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - South - Primary Care	1251 Wesley Dr	Memphis	TN	Active
DSH440049FT	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Weight Management - Bariatrics	57 Germantown Ct	Cordova	TN	Active
DSH440049FU	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Total Health - Total Health	1204 West Poplar Ave	Collierville	TN	Terminated
DSH440049FV	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Germantown Infusion Center - Infusion Center	2170 S Germantown Rd	Germantown	TN	Active
DSH440049FW	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UTMP Medical Oncology - Medical Oncology	1265 Union Ave	Memphis	TN	Active
DSH440049FX	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Medical Group - Neurology	1325 Eastmoreland Ave	Memphis	TN	Active
DSH440049FY	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Sutherland - Cardiology Clinic	57 Germantown Ct	Cordova	TN	Active
DSH440049FZ	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Germantown - Infusion Clinic	7655 Poplar Ave	Germantown	TN	Active
DSH440049G	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Oncology	240 Grandview Dr	Brighton	TN	Terminated
DSH440049GA	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UT Methodist Physicians - Cardiology	1211 Union Ave	Memphis	TN	Active
DSH440049GB	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	UT Methodist Physicians - Bariatric Surgery - Collierville	1204 W Poplar Ave	Collierville	TN	Active
DSH440049J	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Oncology Clinic	7668 Airways Blvd	Southaven	MS	Terminated
DSH440049K	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Labor and Delivery	1300 Wesley Dr	Memphis	TN	Active
DSH440049L	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Respiratory Therapy	1300 Wesley Dr	Memphis	TN	Active
DSH440049M	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Operating Room	1300 Wesley Dr	Memphis	TN	Active
DSH440049N	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Same Day Surgery	1300 Wesley Dr	Memphis	TN	Active
DSH440049P	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - GI Lab	1300 Wesley Dr	Memphis	TN	Active
DSH440049Q	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Emergency Department	1300 Wesley Dr	Memphis	TN	Active
DSH440049R	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Non-Acute Area	1300 Wesley Dr	Memphis	TN	Active
DSH440049S	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Cardiovascular Services	1300 Wesley Dr	Memphis	TN	Active
DSH440049T	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Catheterization Lab	1300 Wesley Dr	Memphis	TN	Active
DSH440049U	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Radiology - Diagnostic	1300 Wesley Dr	Memphis	TN	Active
DSH440049V	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Radiology - CT Scan	1300 Wesley Dr	Memphis	TN	Active
DSH440049W	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - MRI	1300 Wesley Dr	Memphis	TN	Active
DSH440049X	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist South Hospital - Nuclear Medicine	1300 Wesley Dr	Memphis	TN	Active
DSH440049Y	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist Comprehensive Wound Care Center	1251 Wesley Dr, Suite 107	Memphis	TN	Active
DSH440049Z	Child	DSH	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	Methodist North Hospital - Operating Room	3960 New Covington Pike	Memphis	TN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 12:30:01 PM	9/4/2024 1:19:36 PM	9/4/2024 1:19 PM
Contacts	Primary Contact	Update	Profile Change Request	Hilty, Chris Pharmacy Supply Chain/ 340B Manager Methodist Healthcare - Memphis Hospitals 9015167570	Hilty, Chris Director - Pharmacy Supply Chain Methodist Le Bonheur Healthcare 9015167570	1/29/2024 7:33 AM
Details	Last Recertification Date	Update	Recertification	9/15/2022 12:28:56 PM	8/29/2023 12:30:01 PM	8/29/2023 12:30 PM
Contacts	Primary Contact	Update	Group Change Request	Bell, Christopher Neil 340B Program Manager Methodist Healthcare- Memphis Hospitals 9015162440	Hilty, Chris Pharmacy Supply Chain/ 340B Manager Methodist Healthcare - Memphis Hospitals 9015167570	4/18/2023 7:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2022 12:28 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		6045088	9/15/2022 12:28 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/15/2022 12:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2022 12:28 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3018431	9/15/2022 12:28 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/15/2022 12:28 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 11:41:32 AM	9/15/2022 12:28:56 PM	9/15/2022 12:28 PM
Details	Last Recertification Date	Update	Recertification	9/1/2020 5:39:54 PM	9/9/2021 11:41:32 AM	9/9/2021 11:41 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1558365890	9/1/2020 5:39 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/1/2020 5:39 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1558365890	9/1/2020 5:39 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/1/2020 5:39 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1558365890	9/1/2020 5:39 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/1/2020 5:39 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1558365890 ( )		9/1/2020 5:39 PM
Details	Last Recertification Date	Update	Recertification	8/29/2019 12:12:15 PM	9/1/2020 5:39:54 PM	9/1/2020 5:39 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 10:32:56 AM	8/29/2019 12:12:15 PM	8/29/2019 12:12 PM
Addresses	Shipping Address	Insert	Change Request		Methodist Medical Group 6401 Poplar Ave Ste 530 Memphis, TN 38119	1/8/2019 8:45 AM
Addresses	Main Address	Update	Change Request	7796 Wolf Trail Cv Germantown, TN 38138	6401 Poplar Ave Ste 530 Memphis, TN 38119	1/8/2019 8:45 AM
Addresses	Shipping Address	Delete	Change Request	Methodist Medical Group 7796 Wolf Trail Cv Germantown, TN 38138		1/8/2019 8:45 AM
Contacts	Authorizing Official	Update	Change Request	MCLEAN, CHRIS SENIOR VP/CFO Methodist Healthcare - Memphis Hospitals 9015160753	Lane, Chuck SVP/Associate CFO Methodist Healthcare - Memphis Hospitals 9015160549	12/6/2018 12:36 PM
Details	Last Recertification Date	Update	Recertification	11/14/2017 1:34:37 PM	8/28/2018 10:32:56 AM	8/28/2018 10:32 AM
Contacts	Primary Contact	Update	Change Request	Apple, Alison L. Administrative Director, Pharmacy Methodist Healthcare - Memphis Hospitals 9015162292	Bell, Christopher Neil 340B Program Manager Methodist Healthcare- Memphis Hospitals 9015162440	4/4/2018 11:37 AM
Details	Entity Name	Update	Recertification	METHODIST H/C MEMPHIS HOSPT.	METHODIST HEALTHCARE - MEMPHIS HOSPITALS	11/16/2017 7:44 AM
Details	Last Recertification Date	Update	Recertification		11/14/2017 1:34:37 PM	11/14/2017 1:34 PM
Contacts	Primary Contact	Update		Apple, Alison L. Administrative Director, Pharmacy 9015162292	Apple, Alison L. Administrative Director, Pharmacy Methodist Healthcare - Memphis Hospitals 9015162292	10/5/2017 5:24 PM
Contacts	Authorizing Official	Update		MCLEAN, CHRIS SENIOR VP/CFO 9015160753	MCLEAN, CHRIS SENIOR VP/CFO Methodist Healthcare - Memphis Hospitals 9015160753	10/2/2017 10:21 AM
Contacts	Signed By	Update		MCLEAN, CHRIS SENIOR VP/CFO 9015160753	MCLEAN, CHRIS SENIOR VP/CFO Methodist Healthcare - Memphis Hospitals 9015160753	10/2/2017 10:21 AM
Contacts	Authorizing Official	Insert			MCLEAN, CHRIS SENIOR VP/CFO 9015160753	7/18/2017 8:47 AM
Contacts	Signed By	Insert			MCLEAN, CHRIS SENIOR VP/CFO 9015160753	7/18/2017 8:47 AM
Contacts	Primary Contact	Insert			Apple, Alison L. Administrative Director, Pharmacy 9015162292	7/13/2017 10:40 AM
Addresses	Main Address	Insert			7796 Wolf Trail Cv Germantown, TN 38138	7/13/2017 10:39 AM
Addresses	Billing Address	Insert			Methodist Healthcare - Memphis Hospitals P.O. Box 41058 Memphis, TN 38104	7/13/2017 10:39 AM
Addresses	Shipping Address	Insert			Methodist Medical Group 7796 Wolf Trail Cv Germantown, TN 38138	7/13/2017 10:39 AM
Addresses	Shipping Address	Insert			Methodist Healthcare Univ. Department of Pharmacy 1265 Union Ave Memphis, TN 38104	7/13/2017 10:39 AM
Dates	Participating Approval Date	Update			5/1/2017 12:00:00 AM	5/1/2017 3:57 PM
Details	State	Update		Pending	Active	5/1/2017 3:57 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	5/1/2017 3:57 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_76117	DSH440049FD	4/10/2017 9:56 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_76117	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Number	Insert			0009485	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: State	Insert			TN	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Number	Insert			620479367	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: State	Insert			TN	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Number	Insert			0440049	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: State	Insert			TN	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Number	Insert			107115105	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: State	Insert			AR	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Number	Insert			00020469	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: State	Insert			MS	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: Number	Insert			620479367	4/6/2017 12:42 PM
Medicaid Billing	Medicaid: State	Insert			MS	4/6/2017 12:42 PM
Medicaid Billing	NPI: Number	Insert			1558365890	4/6/2017 12:42 PM
Details	Last Recertification Date	Insert				4/6/2017 12:42 PM
Details	Grant Number	Insert				4/6/2017 12:42 PM
Details	340B ID	Insert				4/6/2017 12:42 PM
Details	Is Authorizing Official EHB Data	Insert				4/6/2017 12:42 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/6/2017 12:42 PM
Details	Medicare Provider Number	Insert			440049	4/6/2017 12:42 PM
Details	Entity Name	Insert			METHODIST H/C MEMPHIS HOSPT.	4/6/2017 12:42 PM
Details	Program Code	Insert			DSH	4/6/2017 12:42 PM
Details	Entity Subname	Insert			Methodist Medical Group - Haque	4/6/2017 12:42 PM
Dates	Participating Approval Date	Insert				4/6/2017 12:42 PM
Details	State	Insert			Pending	4/6/2017 12:42 PM
Dates	Registration Date	Insert			4/6/2017 12:00:00 AM	4/6/2017 12:42 PM
Dates	Signed By Date	Insert			4/6/2017 12:00:00 AM	4/6/2017 12:42 PM
Dates	Start Date	Insert				4/6/2017 12:42 PM
Terminations	Termination Comments	Insert				4/6/2017 12:42 PM
Terminations	Termination Date	Insert				4/6/2017 12:42 PM
Terminations	Termination Effective Date	Insert				4/6/2017 12:42 PM
Terminations	Termination Reason	Insert				4/6/2017 12:42 PM