Covered Entity Details

CAH451380-03 East Texas Medical Center Quitman (Terminated) - information as of 5/5/2025 11:54:56 PM

Main Details

Name

East Texas Medical Center Quitman

Subdivision Name

ETMC First Physicians Clinic Grand Saline

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH451380-03

Medicare Provider Number

451380

Outpatient Facility Provider Number

673444

Additional Details

Current Program Status

Terminated

Registration Date

4/10/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/19/2017

Last Recertification Date

11/6/2017

Termination Date
Termination Reason

4/1/2018
For-Profit conversion

Contacts

Authorizing Official

ETMC Quitman
Patrick Swindle, Administrator
(903) 763-6300

Primary Contact

ETMC Quitman
Kathryn Nicole Whitehead, Pharmacy Supervisor
(903) 763-6379

Addresses

Street Address

801 N Waldrip St
Grand Saline, TX 75140

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	364992301

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
CAH451380-01	Child	CAH	East Texas Medical Center Quitman	EAST TEXAS MEDICAL CENTER-MINEOLA C	1220 N. Pacific St	MINEOLA	TX	Terminated
CAH451380-02	Child	CAH	East Texas Medical Center Quitman	ETMC FIRST PHYSICIANS CLINIC QUITMA	117 NORTH WINNSBORO ST.	QUITMAN	TX	Terminated
CAH451380-03	Child	CAH	East Texas Medical Center Quitman	ETMC First Physicians Clinic Grand Saline	801 N Waldrip St	Grand Saline	TX	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/28/2018 12:00:00 AM	2/27/2018 7:25 AM
Details	State	Update	Termination Request	Active	To Be Terminated	2/27/2018 7:25 AM
Terminations	Termination Comments	Update	Termination Request		Changing from a non-profit entity to a for-profit.	2/27/2018 7:25 AM
Terminations	Termination Date	Update	Termination Request		4/1/2018 12:00:00 AM	2/27/2018 7:25 AM
Terminations	Termination Effective Date	Update	Termination Request		3/1/2018 12:00:00 AM	2/27/2018 7:25 AM
Terminations	Termination Reason	Update	Termination Request		For-Profit conversion	2/27/2018 7:25 AM
Details	Last Recertification Date	Update	Recertification	10/24/2017 9:52:06 AM	11/6/2017 9:55:02 AM	11/6/2017 9:55 AM
Details	Entity Name	Update	Recertification	ETMC QUITMAN	East Texas Medical Center Quitman	10/24/2017 9:55 AM
Contacts	Primary Contact	Insert	Recertification		Whitehead, Kathryn Nicole Pharmacy Supervisor ETMC Quitman 9037636379	10/24/2017 9:52 AM
Details	Last Recertification Date	Update	Recertification		10/24/2017 9:52:06 AM	10/24/2017 9:52 AM
Contacts	Authorizing Official	Update		Swindle, Patrick Administrator 9037636300	Swindle, Patrick Administrator ETMC Quitman 9037636300	10/23/2017 3:07 PM
Contacts	Signed By	Update		Swindle, Patrick Administrator 9037636300	Swindle, Patrick Administrator ETMC Quitman 9037636300	10/23/2017 3:07 PM
Contacts	Authorizing Official	Insert			Swindle, Patrick Administrator 9037636300	4/19/2017 10:53 AM
Contacts	Signed By	Insert			Swindle, Patrick Administrator 9037636300	4/19/2017 10:53 AM
Addresses	Main Address	Insert			801 N Waldrip St Grand Saline, TX 75140	4/19/2017 10:53 AM
Dates	Participating Approval Date	Update			4/19/2017 12:00:00 AM	4/19/2017 10:52 AM
Details	State	Update		Pending	Active	4/19/2017 10:52 AM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/19/2017 10:52 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_76297	CAH451380-03	4/14/2017 12:49 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_76297	4/10/2017 11:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/10/2017 11:21 AM
Medicaid Billing	Medicaid: Number	Insert			364992301	4/10/2017 11:21 AM
Medicaid Billing	Medicaid: State	Insert			TX	4/10/2017 11:21 AM
Details	Last Recertification Date	Insert				4/10/2017 11:21 AM
Details	Grant Number	Insert				4/10/2017 11:21 AM
Details	340B ID	Insert				4/10/2017 11:21 AM
Details	Is Authorizing Official EHB Data	Insert				4/10/2017 11:21 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/10/2017 11:21 AM
Details	Medicare Provider Number	Insert			451380	4/10/2017 11:21 AM
Details	Entity Name	Insert			ETMC QUITMAN	4/10/2017 11:21 AM
Details	Program Code	Insert			CAH	4/10/2017 11:21 AM
Details	Entity Subname	Insert			ETMC First Physicians Clinic Grand Saline	4/10/2017 11:21 AM
Dates	Participating Approval Date	Insert				4/10/2017 11:21 AM
Details	State	Insert			Pending	4/10/2017 11:21 AM
Dates	Registration Date	Insert			4/10/2017 12:00:00 AM	4/10/2017 11:21 AM
Dates	Signed By Date	Insert			4/10/2017 12:00:00 AM	4/10/2017 11:21 AM
Dates	Start Date	Insert				4/10/2017 11:21 AM
Terminations	Termination Comments	Insert				4/10/2017 11:21 AM
Terminations	Termination Date	Insert				4/10/2017 11:21 AM
Terminations	Termination Effective Date	Insert				4/10/2017 11:21 AM
Terminations	Termination Reason	Insert				4/10/2017 11:21 AM