Covered Entity Details

DSH450068BT Memorial Hermann Texas Medical Center (Terminated) - information as of 6/5/2025 2:37:45 PM

Main Details

Name

Memorial Hermann Texas Medical Center

Subdivision Name

MH Orthopedic and Spine Hospital - Pain Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450068BT

Medicare Provider Number

450068

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/17/2018

Participating Start Date

10/1/2018

Participating Approval Date

7/31/2018

Last Recertification Date

8/17/2021

Termination Date
Termination Reason

10/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Memorial Hermann Health System
Jessica Ann Graham, Chief Financial Officer
(843) 408-6835

Primary Contact

Memorial Hermann
Eric John Wucki, Director of Pharmacy-340B
(262) 527-2475

Addresses

Street Address

5410 West Loop South
Bellaire, TX 77401

Billing Address

Memorial Hermann
929 Gessner Rd, Suite 2690
Houston, TX 77024

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	137805107	1982666111

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
DSH450068A	Child	DSH	Memorial Hermann Texas Medical Center	Radiology Diagnostic-Mammography	6400 Fannin	Houston	TX	Active
DSH450068AA	Child	DSH	MEMORIAL HERMANN TEXAS MEDICAL CNTR	TMC Breast Center	6400 Fannin, #1600	Houston	TX	Terminated
DSH450068AF	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital - Operating Room	5410 West Loop South	Bellaire	TX	Active
DSH450068AG	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital - SMR Physical Therapy	5420 West Loop South, #1400	Bellaire	TX	Active
DSH450068AH	Child	DSH	MEMORIAL HERMANN TEXAS MEDICAL CNTR	Operating Room	5410 West Loop South	Bellaire	TX	Terminated
DSH450068AJ	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital - Day Surgery	5410 West Loop South	Bellaire	TX	Terminated
DSH450068AK	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital-Post Anesthesia Care Unit	5410 West Loop South	Bellaire	TX	Active
DSH450068AL	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital - Physical Therapy	5410 West Loop South	Bellaire	TX	Active
DSH450068AM	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital - Respiratory Therapy	5410 West Loop South	Bellaire	TX	Active
DSH450068AN	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital - Magnetic Resonance Imaging	5410 West Loop South	Bellaire	TX	Active
DSH450068AP	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital - Radiology Diagnostic	5410 West Loop South	Bellaire	TX	Active
DSH450068AQ	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Rockets Orthopedic Hospital - Anesthesia	5410 West Loop South	Bellaire	TX	Active
DSH450068AR	Child	DSH	Memorial Hermann Texas Medical Center	Alief Clinic	12360 Bear Ram Road #T-1	Houston	TX	Terminated
DSH450068AS	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Ultrasound	27800 Northwest Freeway	Cypress	TX	Active
DSH450068AT	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress- Noninvasive Cardiology	27800 Northwest Freeway	Cypress	TX	Active
DSH450068AU	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress- CT Scan	27800 Northwest Freeway	Cypress	TX	Active
DSH450068AV	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Endoscopy	27800 Northwest Freeway	Cypress	TX	Active
DSH450068AW	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Operating Room	27800 Northwest Freeway	Cypress	TX	Active
DSH450068AX	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Labor and Delivery	27800 Northwest Freeway	Cypress	TX	Active
DSH450068AY	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress-MRI Imaging	27800 Northwest Freeway	Cypress	TX	Active
DSH450068AZ	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Anesthesiology	27800 Northwest Freeway	Cypress	TX	Active
DSH450068B	Child	DSH	Memorial Hermann Texas Medical Center	TMC Radiology Diagnostic Ultrasound (Breast Center)	6400 Fannin, #1600	Houston	TX	Active
DSH450068BA	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Breast Center Outpatient Imaging - Mammography	27700 Northwest Freeway, #140	Cypress	TX	Active
DSH450068BB	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Emergency Room	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BC	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress-Nuclear Medicine	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BD	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress-Cardiac Cath Lab	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BE	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Diagnostic Radiology Imaging - XRAY	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BF	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress -Cardiac Cathlab Recovery	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BG	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress-Cardiopulmonary	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BH	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Recovery Room	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BJ	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Pre-OP	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BK	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Outpatient Imaging - Diagnostic Radiology (X-Ray)	27700 Northwest Freeway, #120	Cypress	TX	Active
DSH450068BL	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Dialysis	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BM	Child	DSH	MEMORIAL HERMANN TEXAS MEDICAL CNTR	Memorial Hermann Cypress - Outpatient Imaging - Mammography - Mammography	27800 Northwest Freeway	Cypress	TX	Terminated
DSH450068BN	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Outpatient Imaging - Cat Scan	27700 Northwest Freeway, #120	Cypress	TX	Active
DSH450068BP	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Breast Outpatient Imaging - Ultrasound	27700 Northwest Freeway, #140	Cypress	TX	Active
DSH450068BQ	Child	DSH	MEMORIAL HERMANN TEXAS MEDICAL CNTR	Memorial Hermann Cypress - Outpatient Observation Unit - Observation Unit	27800 Northwest Freeway	Cypress	TX	Terminated
DSH450068BR	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress - Outpatient Imaging - Ultrasound	27700 Northwest Freeway, #120	Cypress	TX	Active
DSH450068BS	Child	DSH	Memorial Hermann Texas Medical Center	Memorial Hermann Cypress- Outpatient Imaging MRI	27700 Northwest Freeway, #120	Cypress	TX	Active
DSH450068BT	Child	DSH	Memorial Hermann Texas Medical Center	MH Orthopedic and Spine Hospital - Pain Center	5410 West Loop South	Bellaire	TX	Terminated
DSH450068BU	Child	DSH	Memorial Hermann Texas Medical Center	Cypress-Wound Care - Wound Care	27700 Northwest Freeway, #170	Cypress	TX	Active
DSH450068BV	Child	DSH	Memorial Hermann Texas Medical Center	Cypress-Family Care - Labor and Delivery	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BW	Child	DSH	Memorial Hermann Texas Medical Center	TMC- Infusion Center - infusion	6400 Fannin, #2900	Houston	TX	Active
DSH450068BX	Child	DSH	Memorial Hermann Texas Medical Center	Cypress- Occupational Health - Occupational Health	27700 Northwest Freeway, #180	Cypress	TX	Active
DSH450068BY	Child	DSH	Memorial Hermann Texas Medical Center	Cypress- Maternal Fetal Medicine - Maternal Fetal Medicine Clinic	27800 Northwest Freeway	Cypress	TX	Active
DSH450068BZ	Child	DSH	Memorial Hermann Texas Medical Center	Upper Kirby - Mammography	2900 Richmond Ave	Houston	TX	Active
DSH450068C	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Radiology Diagnostic	6400 Fannin, #1600	Houston	TX	Active
DSH450068CA	Child	DSH	Memorial Hermann Texas Medical Center	MH Orthopedic and Spine Hospital - CT Scan	5410 West Loop South	Bellaire	TX	Active
DSH450068CB	Child	DSH	Memorial Hermann Texas Medical Center	Cypress - Lab	27800 Northwest Freeway	Cypress	TX	Active
DSH450068CC	Child	DSH	Memorial Hermann Texas Medical Center	Center for Advanced Heart Failure- Sugar Land - Cardiology	17520 West Grand Pkwy South, #400	Sugar Land	TX	Active
DSH450068CD	Child	DSH	Memorial Hermann Texas Medical Center	Center for Advanced Heart Failure- the Woodlands - cardiology	1120 Medical Plaza Drive #150	Shenandoah	TX	Terminated
DSH450068CE	Child	DSH	Memorial Hermann Texas Medical Center	Center for Advanced Heart Failure- Northwest - Cardiology	1631 North Loop West, #250	Houston	TX	Active
DSH450068CF	Child	DSH	Memorial Hermann Texas Medical Center	Center for Advanced Heart Failure- Katy - Cardiology	23960 Katy Fwy, # 200	Katy	TX	Active
DSH450068CG	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Transplant Clinic - Transplant	6410 Fannin St, Suite 225	Houston	TX	Terminated
DSH450068CH	Child	DSH	Memorial Hermann Texas Medical Center	TMC - Medication Therapy and Wellness Clinic	6400 Fanin St.	Houston	TX	Active
DSH450068D	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Radiology Therapeutic	6400 Fannin, #220	Houston	TX	Active
DSH450068E	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Outpatient Nuclear Medicine	6400 Fannin, #1600	Houston	TX	Active
DSH450068F	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Outpatient CT Scan	6400 Fannin, #1600	Houston	TX	Active
DSH450068G	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Outpatient MRI	6400 Fannin, #1600	Houston	TX	Active
DSH450068H	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Physical Therapy Cardiac Rehab	6414 Fannin, Suite G 100	Houston	TX	Active
DSH450068J	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Digestive Disease Center	6400 Fannin, #1400	Houston	TX	Active
DSH450068K	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Gastroenterology Clinic	6400 Fannin,#1400	Houston	TX	Active
DSH450068L	Child	DSH	Memorial Hermann Texas Medical Center	TMC-Cancer Center	6400 Fannin, #2900	Houston	TX	Active
DSH450068M	Child	DSH	Memorial Hermann Texas Medical Center	Lamar Clinic	1002 E. Stadium Drive	Rosenberg	TX	Terminated
DSH450068N	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging Center Bellaire / Diagnostic Radiology	6700 West Loop South, #100	Bellaire	TX	Active
DSH450068P	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging Bellaire / CT Scan	6700 West Loop South, #100	Bellaire	TX	Active
DSH450068Q	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging Bellaire / MRI	6700 West Loop South, #100	Bellaire	TX	Active
DSH450068R	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging Bellaire / Ultrasound	6700 West Loop South, #100	Bellaire	TX	Active
DSH450068S	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging - Upper Kirby / Radiology Diagnostic	2900 Richmond Ave	Houston	TX	Active
DSH450068T	Child	DSH	MEMORIAL HERMANN TEXAS MEDICAL CNTR	MH Outpatient Imaging - Upper Kirby / Mammography	2900 Richmond Ave.	Houston	TX	Terminated
DSH450068U	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging - Upper Kirby / Ultrasound	2900 Richmond Ave.	Houston	TX	Active
DSH450068V	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging - Upper Kirby / Nuclear Radiology	2900 Richmond Ave.	Houston	TX	Active
DSH450068W	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging - Upper Kirby / CT Scan	2900 Richmond Ave.	Houston	TX	Active
DSH450068X	Child	DSH	Memorial Hermann Texas Medical Center	MH Outpatient Imaging - Upper Kirby / MRI	2900 Richmond Ave.	Houston	TX	Active
DSH450068Y	Child	DSH	Memorial Hermann Texas Medical Center	Acute Heart Failure Clinic	6400 Fannin	Houston	TX	Active
DSH450068Z	Child	DSH	Memorial Hermann Texas Medical Center	PET/CT Scan	6400 Fannin, #1600	Houston	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Wucki, Eric John 340B Manager Memorial Hermann 2625272475	Wucki, Eric John Director of Pharmacy-340B Memorial Hermann 2625272475	8/5/2024 1:13 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		10/1/2022 12:00:00 AM	9/13/2022 12:40 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/13/2022 12:40 PM
Terminations	Termination Date	Update	Recertification		10/1/2022 12:00:00 AM	9/13/2022 12:40 PM
Terminations	Termination Effective Date	Update	Recertification		10/1/2022 12:00:00 AM	9/13/2022 12:40 PM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	9/13/2022 12:40 PM
Details	Last Recertification Date	Update	Recertification	9/13/2020 8:44:50 PM	8/17/2021 4:54:04 PM	8/17/2021 4:54 PM
Contacts	Primary Contact	Update	Change Request	Rangel, Illiana 340B Manager Memorial Hermann 7132422858	Wucki, Eric John 340B Manager Memorial Hermann 2625272475	5/12/2021 12:21 PM
Contacts	Authorizing Official	Update	AO Change Request	Lee, Bryan VP, Finance Memorial Hermann TMC 7137044710	Graham, Jessica Ann Chief Financial Officer Memorial Hermann Health System 8434086835	11/18/2020 12:54 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1982666111	9/13/2020 8:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/13/2020 8:44 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1982666111 ( )		9/13/2020 8:44 PM
Details	Last Recertification Date	Update	Recertification	9/16/2019 11:33:51 AM	9/13/2020 8:44:50 PM	9/13/2020 8:44 PM
Details	Entity Name	Update	Change Request	MEMORIAL HERMANN TEXAS MEDICAL CNTR	Memorial Hermann Texas Medical Center	4/21/2020 3:34 PM
Addresses	Billing Address	Insert	Recertification		Memorial Hermann 929 Gessner Rd, Suite 2690 Houston, TX 77024	9/16/2019 11:33 AM
Details	Last Recertification Date	Update	Recertification		9/16/2019 11:33:51 AM	9/16/2019 11:33 AM
Contacts	Primary Contact	Update	Change Request	Maack, Jo Ann System Pharmacy Director Memorial Hermann System 7132422814	Rangel, Illiana 340B Manager Memorial Hermann 7132422858	8/13/2019 7:08 AM
Details	State	Update		Approved	Active	10/1/2018 12:05 AM
Contacts	Signed By	Insert	New Registration		Lee, Bryan VP, Finance Memorial Hermann TMC 7137044710	7/31/2018 8:21 AM
Details	340B ID	Update	New Registration		DSH450068BT	7/31/2018 8:21 AM
Details	Entity Subname	Update	New Registration	MH Orthopedic and Spine Hospital	MH Orthopedic and Spine Hospital - Pain Center	7/31/2018 8:21 AM
Dates	Participating Approval Date	Update	New Registration		7/31/2018 8:21:05 AM	7/31/2018 8:21 AM
Details	State	Update	New Registration	Pending	Approved	7/31/2018 8:21 AM
Dates	Signed By Date	Update	New Registration		7/17/2018 5:22:57 PM	7/31/2018 8:21 AM
Dates	Start Date	Update	New Registration		10/1/2018 12:00:00 AM	7/31/2018 8:21 AM
Addresses	Main Address	Insert	New Registration		5410 West Loop South Bellaire, TX 77401	7/17/2018 4:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/17/2018 4:37 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		137805107	7/17/2018 4:37 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	7/17/2018 4:37 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982666111	7/17/2018 4:37 PM
Contacts	Primary Contact	Insert	New Registration		Maack, Jo Ann System Pharmacy Director Memorial Hermann System 7132422814	7/17/2018 4:37 PM
Contacts	Authorizing Official	Insert	New Registration		Lee, Bryan VP, Finance Memorial Hermann TMC 7137044710	7/17/2018 4:37 PM
Details	Last Recertification Date	Insert	New Registration			7/17/2018 4:37 PM
Details	Grant Number	Insert	New Registration			7/17/2018 4:37 PM
Details	340B ID	Insert	New Registration			7/17/2018 4:37 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/17/2018 4:37 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/17/2018 4:37 PM
Details	Medicare Provider Number	Insert	New Registration		450068	7/17/2018 4:37 PM
Details	Entity Name	Insert	New Registration		MEMORIAL HERMANN TEXAS MEDICAL CNTR	7/17/2018 4:37 PM
Details	Program Code	Insert	New Registration		DSH	7/17/2018 4:37 PM
Details	Entity Subname	Insert	New Registration		MH Orthopedic and Spine Hospital	7/17/2018 4:37 PM
Dates	Participating Approval Date	Insert	New Registration			7/17/2018 4:37 PM
Details	State	Insert	New Registration		Pending	7/17/2018 4:37 PM
Dates	Registration Date	Insert	New Registration		7/17/2018 4:37:25 PM	7/17/2018 4:37 PM
Dates	Signed By Date	Insert	New Registration			7/17/2018 4:37 PM
Dates	Start Date	Insert	New Registration			7/17/2018 4:37 PM
Terminations	Termination Comments	Insert	New Registration			7/17/2018 4:37 PM
Terminations	Termination Date	Insert	New Registration			7/17/2018 4:37 PM
Terminations	Termination Effective Date	Insert	New Registration			7/17/2018 4:37 PM
Terminations	Termination Reason	Insert	New Registration			7/17/2018 4:37 PM