Covered Entity Details

DSH450684W MEMORIAL HERMANN NORTHEAST HOSPITAL (Active) - information as of 4/29/2025 11:56:40 PM

Main Details

Name

MEMORIAL HERMANN NORTHEAST HOSPITAL

Subdivision Name

Kingwood Convenient Center - Emergency

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450684W

Medicare Provider Number

450684

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/3/2019

Participating Start Date

10/1/2019

Participating Approval Date

7/12/2019

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Memorial Hermann
Robert C Ogden, Associate Vice President of Finance
(713) 456-5111

Primary Contact

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

Addresses

Street Address

4533 Kingwood Drive
Kingwood, TX 77345

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	192751901	1295843787

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
DSH450684A	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Burbank Clinic	315 Berry Road	Houston	TX	Terminated
DSH450684B	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Cancer Center	18960 N. Memorial Drive	Humble	TX	Active
DSH450684C	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Wound Care Center	18960 N. Memorial Drive	Humble	TX	Active
DSH450684D	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	OPID-PET/CT	18955 N. Memorial Drive #100	Humble	TX	Active
DSH450684E	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Summer Creek-Emergency Room	14201 E. Sam Houston Parkway North	Houston	TX	Active
DSH450684F	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	OPID-MRI	18955 N. Memorial Drive #100	Humble	TX	Active
DSH450684G	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	OPID-CT	18955 N. Memorial Drive #100	Humble	TX	Active
DSH450684H	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	OPID-Ultrasound	18955 N. Memorial Drive #100	Humble	TX	Active
DSH450684J	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	OPID-Mammography	18955 N. Memorial Drive #100	Humble	TX	Active
DSH450684K	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Summer Creek-Outpatient X-ray	14201 E. Sam Houston Parkway North	Houston	TX	Active
DSH450684L	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	OPID-XRay	18955 N. Memorial Drive #100	Humble	TX	Active
DSH450684M	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Summer Creek-Outpatient Ultrasound	14201 E. Sam Houston Parkway North	Houston	TX	Active
DSH450684N	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Summer Creek-Outpatient CT	14201 E. Sam Houston Parkway North	Houston	TX	Active
DSH450684P	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Summer Creek - MRI	14201 E. Sam Houston Parkway North	Houston	TX	Terminated
DSH450684Q	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Nimetz Clinic	2003 W. W. Thorne Drive, #TM-01	Houston	TX	Terminated
DSH450684R	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Infusion Center - Outpatient Infusion	18960 N. Memorial Drive	Humble	TX	Active
DSH450684S	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Kingwood Outpatient Imaging - Ultrasound - Radiology Diagnostic	4533 Kingwood Drive	Kingwood	TX	Active
DSH450684T	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Kingwood Outpatient Imaging - CT Scan - CT Scan	4533 Kingwood Drive	Kingwood	TX	Active
DSH450684U	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Kingwood Outpatient Imaging-XRay - Diagnostic Radiology	4533 Kingwood Drive	Kingwood	TX	Active
DSH450684V	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Kingwood Outpatient Imaging - Mammography - Radiology Diagnostic	4533 Kingwood Drive	Kingwood	TX	Active
DSH450684W	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Kingwood Convenient Center - Emergency	4533 Kingwood Drive	Kingwood	TX	Active
DSH450684X	Child	DSH	MEMORIAL HERMANN NORTHEAST HOSPITAL	Kingwood Outpatient Imaging - MRI - Magnetic Resonance Imaging	4533 Kingwood Drive	Kingwood	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/30/2023 10:13:50 AM	8/19/2024 10:49:20 AM	8/19/2024 10:49 AM
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	Last Recertification Date	Update	Recertification	9/7/2022 3:47:28 PM	8/30/2023 10:13:50 AM	8/30/2023 10:13 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1364861 (TX)		11/29/2022 5:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/29/2022 5:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		192751901	11/29/2022 5:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	11/29/2022 5:45 PM
Details	Last Recertification Date	Update	Recertification	8/30/2021 2:48:24 PM	9/7/2022 3:47:28 PM	9/7/2022 3:47 PM
Details	Last Recertification Date	Update	Recertification	9/11/2020 1:35:46 PM	8/30/2021 2:48:24 PM	8/30/2021 2:48 PM
Contacts	Primary Contact	Update	Change Request	Rangel, Illiana 340B Manager Memorial Hermann 7132422858	Wucki, Eric John 340B Manager Memorial Hermann 2625272475	4/16/2021 10:45 AM
Contacts	Authorizing Official	Update	AO Change Request	Reid, Randy VP, Finance Memorial Hermann 2815407802	Ogden, Robert C Associate Vice President of Finance Memorial Hermann 7134565111	2/4/2021 12:25 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1295843787 ( )		9/11/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295843787	9/11/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/11/2020 1:35 PM
Details	Last Recertification Date	Update	Recertification		9/11/2020 1:35:46 PM	9/11/2020 1:35 PM
Addresses	Billing Address	Insert	Change Request		Memorial Hermann 929 Gessner Rd, Suite 2690 Houston, TX 77024	1/15/2020 11:55 AM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Primary Contact	Update	Change Request	Maack, Jo Ann System Pharmacy Director Memorial Hermann System 7132422814	Rangel, Illiana 340B Manager Memorial Hermann 7132422858	8/2/2019 10:00 AM
Contacts	Signed By	Insert	New Registration		Reid, Randy VP, Finance Memorial Hermann 2815407802	7/12/2019 10:31 AM
Details	340B ID	Update	New Registration		DSH450684W	7/12/2019 10:31 AM
Details	Entity Name	Update	New Registration	MEMORIAL HERMANN NORTHEAST	MEMORIAL HERMANN NORTHEAST HOSPITAL	7/12/2019 10:31 AM
Details	Entity Subname	Update	New Registration	Kingwood Convenient Center	Kingwood Convenient Center - Emergency	7/12/2019 10:31 AM
Dates	Participating Approval Date	Update	New Registration		7/12/2019 10:31:11 AM	7/12/2019 10:31 AM
Details	State	Update	New Registration	Pending	Approved	7/12/2019 10:31 AM
Dates	Signed By Date	Update	New Registration		7/3/2019 3:16:36 PM	7/12/2019 10:31 AM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	7/12/2019 10:31 AM
Addresses	Main Address	Insert	New Registration		4533 Kingwood Drive Kingwood, TX 77345	7/3/2019 2:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/3/2019 2:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1364861	7/3/2019 2:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	7/3/2019 2:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1295843787	7/3/2019 2:02 PM
Contacts	Primary Contact	Insert	New Registration		Maack, Jo Ann System Pharmacy Director Memorial Hermann System 7132422814	7/3/2019 2:02 PM
Contacts	Authorizing Official	Insert	New Registration		Reid, Randy VP, Finance Memorial Hermann 2815407802	7/3/2019 2:02 PM
Details	Last Recertification Date	Insert	New Registration			7/3/2019 2:02 PM
Details	Grant Number	Insert	New Registration			7/3/2019 2:02 PM
Details	340B ID	Insert	New Registration			7/3/2019 2:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/3/2019 2:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/3/2019 2:02 PM
Details	Medicare Provider Number	Insert	New Registration		450684	7/3/2019 2:02 PM
Details	Entity Name	Insert	New Registration		MEMORIAL HERMANN NORTHEAST	7/3/2019 2:02 PM
Details	Program Code	Insert	New Registration		DSH	7/3/2019 2:02 PM
Details	Entity Subname	Insert	New Registration		Kingwood Convenient Center	7/3/2019 2:02 PM
Dates	Participating Approval Date	Insert	New Registration			7/3/2019 2:02 PM
Details	State	Insert	New Registration		Pending	7/3/2019 2:02 PM
Dates	Registration Date	Insert	New Registration		7/3/2019 2:02:41 PM	7/3/2019 2:02 PM
Dates	Signed By Date	Insert	New Registration			7/3/2019 2:02 PM
Dates	Start Date	Insert	New Registration			7/3/2019 2:02 PM
Terminations	Termination Comments	Insert	New Registration			7/3/2019 2:02 PM
Terminations	Termination Date	Insert	New Registration			7/3/2019 2:02 PM
Terminations	Termination Effective Date	Insert	New Registration			7/3/2019 2:02 PM
Terminations	Termination Reason	Insert	New Registration			7/3/2019 2:02 PM