| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 6/1/2025 12:00:00 AM | 4/14/2025 2:09 PM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 4/14/2025 2:09 PM |
| Terminations | Termination Date | Update | Termination Request | | 7/1/2025 12:00:00 AM | 4/14/2025 2:09 PM |
| Terminations | Termination Effective Date | Update | Termination Request | | 6/2/2025 12:00:00 AM | 4/14/2025 2:09 PM |
| Terminations | Termination Reason | Update | Termination Request | | Hospital Outpatient facility no longer eligible | 4/14/2025 2:09 PM |
| Details | Last Recertification Date | Update | Recertification | 8/15/2023 6:55:09 PM | 8/13/2024 6:33:05 PM | 8/13/2024 6:33 PM |
| Details | Entity Subname | Update | Change Request | Houston Methodist Emergency Care Center in | Houston Methodist Emergency Care Center in Cypress | 4/4/2024 8:13 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 140732201 (TX) | | 1/16/2024 8:24 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 140713201 (TX) | | 1/16/2024 8:24 AM |
| Details | Entity Subname | Update | Change Request | Emergency Care Center in Cypress - Emergency Care | Houston Methodist Emergency Care Center in | 1/16/2024 8:24 AM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2022 9:12:10 AM | 8/15/2023 6:55:09 PM | 8/15/2023 6:55 PM |
| 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 |
27560 US-290 Frontage
Cypress, TX 77433 |
27560 HIGHWAY 290
Cypress, TX 77433-4909 | 10/18/2022 11:15 AM |
| Addresses | Billing Address | Update | Change Request | HOUSTON METHODIST WILLOWBROOK HOSPITAL
18220 Tomball Parkway (Hwy 249)
Houston, TX 77070 | HOUSTON METHODIST WILLOWBROOK HOSPITAL
18220 STATE HIGHWAY 249
Houston, TX 77070-4347 | 10/18/2022 11:15 AM |
| Addresses | Shipping Address | Update | Change Request | HOUSTON METHODIST WILLOWBROOK HOSPITAL
18220 Tomball Parkway (Hwy 249)
Houston, TX 77070 | HOUSTON METHODIST WILLOWBROOK HOSPITAL
18220 STATE HIGHWAY 249
Houston, TX 77070-4347 | 10/18/2022 11:15 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 9:49:35 AM | 9/7/2022 9:12:10 AM | 9/7/2022 9:12 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 10:10 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 140732201 | 7/11/2022 10:10 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | TX | 7/11/2022 10:10 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2020 9:56:47 AM | 8/27/2021 9:49:35 AM | 8/27/2021 9:49 AM |
| Addresses | Billing Address | Insert | Change Request | | HOUSTON METHODIST WILLOWBROOK HOSPITAL
18220 Tomball Parkway (Hwy 249)
Houston, TX 77070 | 1/14/2021 8:54 AM |
| Addresses | Shipping Address | Insert | Change Request | | HOUSTON METHODIST WILLOWBROOK HOSPITAL
18220 Tomball Parkway (Hwy 249)
Houston, TX 77070 | 1/14/2021 8:54 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1871619254 | 9/8/2020 9:56 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | TX | 9/8/2020 9:56 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1871619254 ( ) | | 9/8/2020 9:56 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2019 11:59:15 AM | 9/8/2020 9:56:47 AM | 9/8/2020 9:56 AM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2018 11:20:02 AM | 8/27/2019 11:59:15 AM | 8/27/2019 11:59 AM |
| 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 11:20:02 AM | 8/23/2018 11:20 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 |
| Details | State | Update | | Approved | Active | 4/1/2018 12:00 AM |
| 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 |
| Contacts | Signed By | Insert | New Registration | | Barber, Keith D
SVP / CEO
Houston Methodist Willowbrook
2817371003 | 2/2/2018 2:14 PM |
| Details | 340B ID | Update | New Registration | | DSH450844A | 2/2/2018 2:14 PM |
| Details | Entity Subname | Update | New Registration | Emergency Care Center in Cypress | Emergency Care Center in Cypress - Emergency Care | 2/2/2018 2:14 PM |
| Dates | Participating Approval Date | Update | New Registration | | 2/2/2018 2:14:37 PM | 2/2/2018 2:14 PM |
| Details | State | Update | New Registration | Pending | Approved | 2/2/2018 2:14 PM |
| Dates | Signed By Date | Update | New Registration | | 1/15/2018 9:22:22 AM | 2/2/2018 2:14 PM |
| Dates | Start Date | Update | New Registration | | 4/1/2018 12:00:00 AM | 2/2/2018 2:14 PM |
| Addresses | Main Address | Insert | New Registration | |
27560 US-290 Frontage
Cypress, TX 77433 | 1/12/2018 10:55 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | New Registration | | False | 1/12/2018 10:55 AM |
| Medicaid Billing | Medicaid: Number | Insert | New Registration | | 140713201 | 1/12/2018 10:55 AM |
| Medicaid Billing | Medicaid: State | Insert | New Registration | | TX | 1/12/2018 10:55 AM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1871619254 | 1/12/2018 10:55 AM |
| Contacts | Authorizing Official | Insert | New Registration | | Barber, Keith D
SVP / CEO
Houston Methodist Willowbrook
2817371003 | 1/12/2018 10:55 AM |
| Contacts | Primary Contact | Insert | New Registration | | Metzen, Daniel
System Director of Pharmacy
Houston Methodist
7134412141 | 1/12/2018 10:55 AM |
| Details | Last Recertification Date | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Details | Grant Number | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Details | 340B ID | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Details | Medicare Provider Number | Insert | New Registration | | 450844 | 1/12/2018 10:55 AM |
| Details | Entity Name | Insert | New Registration | | METHODIST WILLOWBROOK HOSPITAL | 1/12/2018 10:55 AM |
| Details | Program Code | Insert | New Registration | | DSH | 1/12/2018 10:55 AM |
| Details | Entity Subname | Insert | New Registration | | Emergency Care Center in Cypress | 1/12/2018 10:55 AM |
| Dates | Participating Approval Date | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Details | State | Insert | New Registration | | Pending | 1/12/2018 10:55 AM |
| Dates | Registration Date | Insert | New Registration | | 1/12/2018 10:55:43 AM | 1/12/2018 10:55 AM |
| Dates | Signed By Date | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Dates | Start Date | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Terminations | Termination Comments | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Terminations | Termination Date | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 1/12/2018 10:55 AM |
| Terminations | Termination Reason | Insert | New Registration | | | 1/12/2018 10:55 AM |