Covered Entity Details

DSH370093L OU MEDICAL CENTER (Active) - information as of 4/25/2025 5:39:04 PM

Main Details

Name

OU MEDICAL CENTER

Subdivision Name

OU MEDICAL CENTER- PRESBY PROF BLDG PAIN MANAGEMENT & SURGERY CLINIC I

Type

Disproportionate Share Hospital

Rural

340B ID

DSH370093L

Medicare Provider Number

370093

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/4/2018

Participating Start Date

7/1/2018

Participating Approval Date

4/20/2018

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

OU Health
Krystal L Murer, Vice President | Ethics, Regulatory Affairs, and Chief Compliance Officer
(405) 271-8052

Primary Contact

OU Health
Oliver Lackey, 340B Director
(405) 543-7101

Addresses

Street Address

711 STANTON L YOUNG BOULEVARD
Suite 619
OKLAHOMA CITY, OK 73104-5023

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
OK	200752850A	1649794157

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
DSH370093A	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER-THE CHILDREN'S HO - Rad CT	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AA	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER-THE CHILDREN'S HOSPITAL - Cath Lab	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AB	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Special Procedures	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093AC	Child	DSH	OU MEDICAL CENTER	OU Health Transplant Institute	920 NE 13th Street	OKLAHOMA CITY	OK	Active
DSH370093AD	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - Rad Diagnostic	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AE	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - Emergency Room	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AF	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - Anesthesia Childrens	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AG	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER- PRESBY PROF BLDG - OU Surgery Clinic	711 STANTON L YOUNG BOULEVARD	OKLAHOMA CITY	OK	Active
DSH370093AH	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Endoscopy	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093AJ	Child	DSH	OU MEDICAL CENTER	BREAST HEALTH NETWORK EDMOND - Edmond Breast Health	2601 KELLEY POINTE PKWY	EDMOND	OK	Active
DSH370093AK	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - Vascular Lab	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AL	Child	DSH	OU MEDICAL CENTER	EDMOND MEDICAL OFFICE BUILDING - Senior Health Clinic Edmond	105 SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093AM	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - EP LAB	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AN	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER- PRESBY PROF BLDG - OU OBGYN Clinic	711 STANTON L YOUNG BOULEVARD	OKLAHOMA CITY	OK	Active
DSH370093AP	Child	DSH	OU MEDICAL CENTER	THE CHILDREN's HOSPTIAL - Dialysis	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Terminated
DSH370093AQ	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER CHILDREN'S PHYSI - Childrens Radiology	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AR	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Emergency Room	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093AS	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond MRI	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093AT	Child	DSH	OU MEDICAL CENTER	SCC Radiology Special Procedures	800 NORTHEAST 10TH STREET	OKLAHOMA CITY	OK	Active
DSH370093AU	Child	DSH	OU MEDICAL CENTER	BREAST HEALTH NETWORK - NW Breast Health Network	13401 N MACARTHUR BLVD	OKLAHOMA CITY	OK	Active
DSH370093AV	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - PT OT	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AW	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Physical Therapy	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093AX	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - Rad Ultrasound	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093AY	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Hemodialysis	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Terminated
DSH370093AZ	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Anesthesia	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093B	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Ultrasound	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093BA	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Radiology Diagnostic	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093BB	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - Respiratory Therapy	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BC	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Sleep Lab	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093BD	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - Dialysis Peds	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BE	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Cath Lab	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093BF	Child	DSH	OU MEDICAL CENTER	OU Physician's Building Imaging	825 Northeast 10th Street	OKLAHOMA CITY	OK	Active
DSH370093BG	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER-Outpatient Surgery Center	700 NORTH EAST 10TH STREET	OKLAHOMA CITY	OK	Active
DSH370093BH	Child	DSH	OU MEDICAL CENTER	OU Physician's Building - Heart Lung Vascular (HLV) Clinic	825 N.E. 10TH STREET	OKLAHOMA CITY	OK	Active
DSH370093BJ	Child	DSH	OU MEDICAL CENTER	OU Medical Center -Stephenson Cancer Center	800 NE 10th Street	Oklahoma City	OK	Active
DSH370093BK	Child	DSH	OU MEDICAL CENTER	OU Medicine - Jimmy Everest Oncology Center	1200 Children's Ave	Oklahoma City	OK	Active
DSH370093BL	Child	DSH	OU MEDICAL CENTER	EDMOND MEDICAL OFFICE BUILDING -Preoperative Clinic and Outpatient Lab - Preoperative Clinic and Outpatient Lab	105 S. Bryant	EDMOND	OK	Active
DSH370093BM	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER- PRESBY PROF BLDG -Medicine Specialty Clinic - Medicine Specialty Clinic	711 STANTON L YOUNG BOULEVARD	Oklahoma City	OK	Active
DSH370093BN	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER- PRESBY PROF BLDG - Orthopedic Clinic - Orthopedic Clinic	711 STANTON L YOUNG BOULEVARD	Oklahoma City	OK	Active
DSH370093BP	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Physical Therapy - Edmond Physical Therapy	305 S. Bryant	EDMOND	OK	Active
DSH370093BQ	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER - Radiation Annex - Radiation Annex	825 NE 10th Street	OKLAHOMA CITY	OK	Active
DSH370093BR	Child	DSH	OU MEDICAL CENTER	OU CHILDRENS NEUROLOGY CLINIC - Children's Neurology Clinic	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BS	Child	DSH	OU MEDICAL CENTER	OU CHILDRENS HEART CENTER - Children's Heart Center	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BT	Child	DSH	OU MEDICAL CENTER	OU CHILDRENS SOONER PEDIATRIC CLIN - Sooner Pediatric Clinic	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BU	Child	DSH	OU MEDICAL CENTER	OU CHILDRENS NEUROSURGERY CLINIC - Children's Neurosurgery Clinic	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BV	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Outpatient Infusion Center - Edmond Outpatient Infusion Center	One South Bryant	Edmond	OK	Active
DSH370093BW	Child	DSH	OU MEDICAL CENTER	OU CHILDRENS SPECIALTY CLINIC - Children's Specialty Clinic	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BX	Child	DSH	OU MEDICAL CENTER	OU CHILDRENS ADOLESCENT MEDICINE CL - Adolescent Medicine Clinic	1200 CHILRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BY	Child	DSH	OU MEDICAL CENTER	OU CHILDRENS GASTRO & HEPATOLOGY - OU Children's Physicians Building - Gastroenterology & Hepatology	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093BZ	Child	DSH	OU MEDICAL CENTER	OU CHILDRENS PDP & CYSTIC FIBROSIS - OU Children's Physicians Building -Pulmonology & Cystic Fibrosis	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093C	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER- PRESBY PROF BLDG - OU Image Clinic	711 STANTON L YOUNG BOULEVARD	OKLAHOMA CITY	OK	Active
DSH370093CA	Child	DSH	OU MEDICAL CENTER	OU CHILDREN'S DIABETES & ENDO - OU Children's Physicians Building - Diabetes & Endocrinology	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093CB	Child	DSH	OU MEDICAL CENTER	OU Health Physicians Building - Neurology Clinic - OU Health Physicians - Neurology Clinic	825 NE 10th Street	Oklahoma City	OK	Active
DSH370093CC	Child	DSH	OU MEDICAL CENTER	OU Health ER & Urgent Care Yukon - OU Health ER & Urgent Care Yukon	709 N. Czech Hall Road	Yukon	OK	Active
DSH370093CD	Child	DSH	OU MEDICAL CENTER	OU Stephenson Cancer Center at Norman Regional - Medical Oncology Infusion - OU Stephenson Cancer Center at Norman Regional - Medical Oncology Infusion	901 N. Porter Ave	Norman	OK	Active
DSH370093CE	Child	DSH	OU MEDICAL CENTER	OU Health Infectious Diseases Clinic - OU Health Infectious Diseases Clinic	711 Stanton L. Young Blvd.	Oklahoma City	OK	Active
DSH370093CF	Child	DSH	OU MEDICAL CENTER	OU Health Reproductive Medicine - OU Health Reproductive Medicine	840 Research Parkway	Oklahoma City	OK	Active
DSH370093CG	Child	DSH	OU MEDICAL CENTER	OU Health Pre-Op Clinic - OU Health Pre-Op Clinic	711 Stanton L. Young Blvd.	Oklahoma City	OK	Active
DSH370093CH	Child	DSH	OU MEDICAL CENTER	OU Health GIM/Medicine Specialty/Senior Health Clinic - OU Health GIM/Medicine Specialty/Senior Health Clinic	1000 NE 13th Street	Oklahoma City	OK	Active
DSH370093CJ	Child	DSH	OU MEDICAL CENTER	OU HEALTH DERMATOLOGY CLINIC - OU HEALTH DERMATOLOGY CLINIC	1000 NE 13TH ST	OKLAHOMA CITY	OK	Active
DSH370093CK	Child	DSH	OU MEDICAL CENTER	OU Stephenson Cancer Center at Norman Regional - Medical Oncology Clinical - OU Stephenson Cancer Center at Norman Regional - Medical Oncology Clinical	901 N. Porter Ave	Norman	OK	Active
DSH370093CL	Child	DSH	OU MEDICAL CENTER	OU HEALTH SCC AT SCHUSTERMAN - Oncology	4444 E 41ST ST	TULSA	OK	Active
DSH370093CM	Child	DSH	OU MEDICAL CENTER	OU HEALTH ER & URGENT CARE - SOUTH - Urgent Care	3025 SW 104TH ST	OKLAHOMA CITY	OK	Active
DSH370093CN	Child	DSH	OU MEDICAL CENTER	OU HEALTH SCC AT HILLCREST - Hillcrest Infusion	1245 S UTICA AVE	TULSA	OK	Active
DSH370093CP	Child	DSH	OU MEDICAL CENTER	OU HEALTH EDMOND GASTROENTEROLOGY - Gastroenterology	105 S BRYANT AVE	EDMOND	OK	Active
DSH370093D	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Laboratory	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093E	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond EEG	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093F	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER- PRESBY PROF BLDG - OU Medicine Clinic	711 STANTON L YOUNG BOULEVARD	OKLAHOMA CITY	OK	Active
DSH370093G	Child	DSH	OU MEDICAL CENTER	OUMC Outpatient Clinic	1122 N.E. 13TH STREET	OKLAHOMA CITY	OK	Terminated
DSH370093H	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond CT Scan	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093J	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Respiratory Therapy	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093K	Child	DSH	OU MEDICAL CENTER	THE CHILDREN'S HOSPITAL - EEG	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093L	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER- PRESBY PROF BLDG PAIN MANAGEMENT & SURGERY CLINIC I	711 STANTON L YOUNG BOULEVARD	OKLAHOMA CITY	OK	Active
DSH370093M	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER CHILDREN'S PHYSI - Peds Echo	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093N	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Recovery	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093P	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Surgery	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093Q	Child	DSH	OU MEDICAL CENTER	BREAST HEALTH NETWORK - SW Breast Health Network	2607 SW 119TH ST	OKLAHOMA CITY	OK	Active
DSH370093R	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond Nuclear Medicine	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093S	Child	DSH	OU MEDICAL CENTER	The Children's Hospital - Sleep Lab	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093T	Child	DSH	OU MEDICAL CENTER	The Children's Hospital - Rad Ther	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093U	Child	DSH	OU MEDICAL CENTER	OUCPB- Peds EKG	1200 CHILDRENS AVE	OKLAHOMA CITY	OK	Active
DSH370093W	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER- PRESBY PROF BLDG - ORL & Plastic Surgery Clinic	711 STANTON L YOUNG BOULEVARD	OKLAHOMA CITY	OK	Active
DSH370093X	Child	DSH	OU MEDICAL CENTER	EDMOND MEDICAL OFFICE BUILDING - Edmond Radiology Clinic	105 SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093Y	Child	DSH	OU MEDICAL CENTER	OU MEDICAL CENTER EDMOND - Edmond EKG	ONE SOUTH BRYANT AVENUE	EDMOND	OK	Active
DSH370093Z	Child	DSH	OU MEDICAL CENTER	OU PHYSICIANS BUILDING - Endoscopy	825 NORTHEAST 10TH STREET	OKLAHOMA CITY	OK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Weckhorst, Kaitlyn 340B Manager OU Health 4056583226	Lackey, Oliver 340B Director OU Health 4055437101	4/7/2025 6:45 AM
Contacts	Primary Contact	Update	PC Change Request	Hale, Stacey D Director, 340B Program OU Medicine 4056152194	Weckhorst, Kaitlyn 340B Manager OU Health 4056583226	1/6/2025 10:51 AM
Details	Last Recertification Date	Update	Recertification	8/23/2023 3:51:38 PM	9/4/2024 2:29:09 PM	9/4/2024 2:29 PM
Contacts	Authorizing Official	Update	Profile Change Request	Murer, Krystal Leighanna Associate Vice President \| Ethics, Regulatory Affairs, and Compliance Officer OU Health 4052718052	Murer, Krystal L Vice President \| Ethics, Regulatory Affairs, and Chief Compliance Officer OU Health 4052718052	4/29/2024 6:36 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 6:57:43 AM	8/23/2023 3:51:38 PM	8/23/2023 3:51 PM
Addresses	Main Address	Update	Recertification	711 STANTON L YOUNG BOULEVARD Suite 619 , 624 OKLAHOMA CITY, OK 73104-5023	711 STANTON L YOUNG BOULEVARD Suite 619 OKLAHOMA CITY, OK 73104-5023	9/1/2022 6:57 AM
Addresses	Shipping Address	Delete	Recertification	OU MEDICAL CENTER- PRESBY PROF BLDG - OU PRE OP Clinic 711 STANTON L YOUNG BOULEVARD Suite 619 , 624 OKLAHOMA CITY, OK 73104-5023		9/1/2022 6:57 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 3:45:26 PM	9/1/2022 6:57:43 AM	9/1/2022 6:57 AM
Details	Entity Subname	Update	Recertification	OU MEDICAL CENTER- PRESBY PROF BLDG - OU PRE OP Clinic	OU MEDICAL CENTER- PRESBY PROF BLDG PAIN MANAGEMENT & SURGERY CLINIC I	9/1/2022 6:57 AM
Contacts	Primary Contact	Update	Group Change Request	Herring, Holly AVP Pharmacy OU Health 5805127188	Hale, Stacey D Director, 340B Program OU Medicine 4056152194	8/23/2022 7:48 AM
Contacts	Authorizing Official	Update	Change Request	Watson, James Michael CFO OU Medicine Inc. 4052715100	Murer, Krystal Leighanna Associate Vice President \| Ethics, Regulatory Affairs, and Compliance Officer OU Health 4052718052	7/21/2022 10:57 AM
Contacts	Primary Contact	Update	Recertification	Herring, PharmD BCPS, Holly R 340B Compliance Manager OU Medicine 4052718001-32069	Herring, Holly AVP Pharmacy OU Health 5805127188	9/9/2021 3:45 PM
Details	Last Recertification Date	Update	Recertification	8/21/2020 4:08:15 PM	9/9/2021 3:45:26 PM	9/9/2021 3:45 PM
Medicaid Billing	NPI: State	Update	Recertification		OK	8/21/2020 4:08 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 1:39:40 PM	8/21/2020 4:08:15 PM	8/21/2020 4:08 PM
Addresses	Shipping Address	Delete	Change Request	OU MEDICAL CENTER- PRESBY PROF BLDG - OU PRE OP Clinic 711 STANTON L YOUNG BOULEVARD OKLAHOMA CITY, OK 73104-5023		7/22/2020 8:23 AM
Addresses	Main Address	Update	Change Request	711 STANTON L YOUNG BOULEVARD OKLAHOMA CITY, OK 73104-5023	711 STANTON L YOUNG BOULEVARD Suite 619 , 624 OKLAHOMA CITY, OK 73104-5023	7/22/2020 8:23 AM
Addresses	Shipping Address	Insert	Change Request		OU MEDICAL CENTER- PRESBY PROF BLDG - OU PRE OP Clinic 711 STANTON L YOUNG BOULEVARD Suite 619 , 624 OKLAHOMA CITY, OK 73104-5023	7/22/2020 8:23 AM
Contacts	Primary Contact	Update	Change Request	Pezewski, David Ian Director of Reimbursement OU Medicine Inc 4052718132-53399	Herring, PharmD BCPS, Holly R 340B Compliance Manager OU Medicine 4052718001-32069	7/22/2020 8:23 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 10:45:04 AM	8/21/2019 1:39:40 PM	8/21/2019 1:39 PM
Details	Last Recertification Date	Update	Recertification		8/15/2018 10:45:04 AM	8/15/2018 10:45 AM
Addresses	Shipping Address	Insert	Change Request		OU MEDICAL CENTER- PRESBY PROF BLDG - OU PRE OP Clinic 711 STANTON L YOUNG BOULEVARD OKLAHOMA CITY, OK 73104-5023	6/28/2018 2:04 PM
Contacts	Primary Contact	Update	Change Request	Jones, Mary Lucille Dir Revenue Integrity OU Medicine Inc 4052718132-53365	Pezewski, David Ian Director of Reimbursement OU Medicine Inc 4052718132-53399	6/28/2018 2:04 PM
Details	State	Update	Change Request	Approved	Active	6/28/2018 2:04 PM
Contacts	Signed By	Insert	New Registration		Watson, James Michael CFO OU Medicine Inc. 4052715100	4/20/2018 1:59 PM
Details	340B ID	Update	New Registration		DSH370093L	4/20/2018 1:59 PM
Details	Entity Name	Update	New Registration	UNIVERSITY HOSPITAL HLTH SOURCE PHARMACY	OU MEDICAL CENTER	4/20/2018 1:59 PM
Details	Entity Subname	Update	New Registration	OU MEDICAL CENTER- PRESBY PROF BLDG	OU MEDICAL CENTER- PRESBY PROF BLDG - OU PRE OP Clinic	4/20/2018 1:59 PM
Dates	Participating Approval Date	Update	New Registration		4/20/2018 1:59:59 PM	4/20/2018 1:59 PM
Details	State	Update	New Registration	Pending	Approved	4/20/2018 1:59 PM
Dates	Signed By Date	Update	New Registration		4/9/2018 5:04:31 PM	4/20/2018 1:59 PM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	4/20/2018 1:59 PM
Addresses	Main Address	Insert	New Registration		711 STANTON L YOUNG BOULEVARD OKLAHOMA CITY, OK 73104-5023	4/4/2018 12:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2018 12:14 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		200752850A	4/4/2018 12:14 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	4/4/2018 12:14 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649794157	4/4/2018 12:14 PM
Contacts	Primary Contact	Insert	New Registration		Jones, Mary Lucille Dir Revenue Integrity OU Medicine Inc 4052718132-53365	4/4/2018 12:14 PM
Contacts	Authorizing Official	Insert	New Registration		Watson, James Michael CFO OU Medicine Inc. 4052715100	4/4/2018 12:14 PM
Details	Last Recertification Date	Insert	New Registration			4/4/2018 12:14 PM
Details	Grant Number	Insert	New Registration			4/4/2018 12:14 PM
Details	340B ID	Insert	New Registration			4/4/2018 12:14 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/4/2018 12:14 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/4/2018 12:14 PM
Details	Medicare Provider Number	Insert	New Registration		370093	4/4/2018 12:14 PM
Details	Entity Name	Insert	New Registration		UNIVERSITY HOSPITAL HLTH SOURCE PHARMACY	4/4/2018 12:14 PM
Details	Program Code	Insert	New Registration		DSH	4/4/2018 12:14 PM
Details	Entity Subname	Insert	New Registration		OU MEDICAL CENTER- PRESBY PROF BLDG	4/4/2018 12:14 PM
Dates	Participating Approval Date	Insert	New Registration			4/4/2018 12:14 PM
Details	State	Insert	New Registration		Pending	4/4/2018 12:14 PM
Dates	Registration Date	Insert	New Registration		4/4/2018 12:14:30 PM	4/4/2018 12:14 PM
Dates	Signed By Date	Insert	New Registration			4/4/2018 12:14 PM
Dates	Start Date	Insert	New Registration			4/4/2018 12:14 PM
Terminations	Termination Comments	Insert	New Registration			4/4/2018 12:14 PM
Terminations	Termination Date	Insert	New Registration			4/4/2018 12:14 PM
Terminations	Termination Effective Date	Insert	New Registration			4/4/2018 12:14 PM
Terminations	Termination Reason	Insert	New Registration			4/4/2018 12:14 PM