Covered Entity Details

DSH450184GB MEMORIAL HERMANN HOSPITAL SYSTEM (Active) - information as of 4/25/2025 9:18:59 PM

Main Details

Name

MEMORIAL HERMANN HOSPITAL SYSTEM

Subdivision Name

HVI-CV Pre-Op - Cardiology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450184GB

Medicare Provider Number

450184

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/11/2019

Participating Start Date

1/1/2020

Participating Approval Date

11/19/2019

Last Recertification Date

9/5/2024

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

7787 Southwest Fwy
Houston, TX 77074

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	020834001	1730132234

Shipping Addresses

Shipping Address 1

Memorial Hermann
7600 Beechnut
Houston, TX 77074

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
DSH450184A	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	MEMORIAL HERMANN SOUTHEAST HOSPITAL	11800 ASTORIA BLVD	HOUSTON	TX	Terminated
DSH450184AA	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Surgery	1635 North Loop West	Houston	TX	Active
DSH450184AB	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Anesthesia	1635 North Loop West	Houston	TX	Active
DSH450184AC	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Radiology - Diagnostic	1635 North Loop West	Houston	TX	Active
DSH450184AD	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Radiology - Therapeutic	1635 North Loop West	Houston	TX	Active
DSH450184AE	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Radioisotope	1635 North Loop West	Houston	TX	Active
DSH450184AF	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Laboratory	1635 North Loop West	Houston	TX	Active
DSH450184AG	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights - Outpatient Respiratory Therapy	1635 North Loop West	Houston	TX	Active
DSH450184AH	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Physical Therapy	1635 North Loop West	Houston	TX	Active
DSH450184AJ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Electrocardiology	1635 North Loop West	Houston	TX	Active
DSH450184AK	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Cardiac Cath	1635 North Loop West	Houston	TX	Active
DSH450184AM	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Electroencephalography	1635 North Loop West	Houston	TX	Active
DSH450184AN	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Renal Dialysis	1635 North Loop West	Houston	TX	Active
DSH450184AO	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Diabetes Education	1635 North Loop West	Houston	TX	Terminated
DSH450184AP	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Emergency	1635 North Loop West	Houston	TX	Active
DSH450184AQ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Observation Beds (Not-Distinct)	1635 North Loop West	Houston	TX	Terminated
DSH450184AR	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Clinical Decision Unit	1635 North Loop West	Houston	TX	Active
DSH450184AS	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Admission Processing Unit	1635 North Loop West	Houston	TX	Terminated
DSH450184AT	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Radiation Oncology Center	1635 North Loop West	Houston	TX	Terminated
DSH450184AU	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Orthopedic and Sports Medicine	1635 North Loop West	Houston	TX	Terminated
DSH450184AV	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Wound Care	1635 North Loop West	Houston	TX	Active
DSH450184AW	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-CT (Friendswood)	1505 E. Winding Way, #100	Friendswood	TX	Terminated
DSH450184AX	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-MRI (Friendswood)	1505 E. Winding Way, #100	Friendswood	TX	Terminated
DSH450184AY	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Ultrasound (Friendswood)	1505 E. Winding Way, #100	Friendswood	TX	Terminated
DSH450184AZ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Mammography (Friendswood)	1505 E. Winding Way, #100	Friendswood	TX	Terminated
DSH450184B	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Surgery	9250 Pinecroft	The Woodlands	TX	Active
DSH450184BA	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Pearland Outpatient Imaging-MRI	10905 Memorial Hermann Drive, Suite 104	Pearland	TX	Active
DSH450184BB	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Pearland Outpatient Imaging-CT	10905 Memorial Hermann Drive, Suite 104	Pearland	TX	Active
DSH450184BC	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Pearland Outpatient Imaging-Ultrasound	10905 Memorial Hermann Drive, Suite 104	Pearland	TX	Active
DSH450184BD	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Pearland Outpatient Imaging-Mammography	10905 Memorial Hermann Drive, Suite 104	Pearland	TX	Active
DSH450184BE	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands-OPID-Radiology Diagnostic	9200 Pinecroft, #100	The Woodlands	TX	Active
DSH450184BF	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands-Emergency Care	9950 Woodlands Pkwy	The Woodlands	TX	Active
DSH450184BH	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Radiology Diagnostic (Friendswood)	1505 E. Winding Way, #100	Friendswood	TX	Terminated
DSH450184BJ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Pearland Outpatient Imaging-Radiology Diagnostic	10905 Memorial Hermann Drive, Suite 104	Pearland	TX	Active
DSH450184BK	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southwest - Outpatient Imaging MRI	7789 Southwest Freeway, Suite 150	Houston	TX	Active
DSH450184BL	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southwest - Outpatient Imaging X-Ray	7789 Southwest Freeway, Suite 150	Houston	TX	Active
DSH450184BM	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southwest - Outpatient Imaging CT	7789 Southwest Freeway, Suite 150	Houston	TX	Active
DSH450184BN	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Hogg Clinic	1100 Merrill Street	Houston	TX	Terminated
DSH450184BP	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	WAVE Clinic	1500 Main St	South Houston	TX	Terminated
DSH450184BQ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-MRI-Clear Lake	16915 El Camino Real	Webster	TX	Terminated
DSH450184BR	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-CAT Scan-Clear Lake	16915 El Camino Real	Webster	TX	Terminated
DSH450184BS	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-Ultrasound-Clear Lake	16915 El Camino Real	Webster	TX	Terminated
DSH450184BT	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-Mammography-Clear Lake	16915 El Camino Real	Webster	TX	Terminated
DSH450184BU	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-Radiology Diagnostic - Clear Lake	16915 El Camino Real	Webster	TX	Terminated
DSH450184BV	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-MRI-Pasadena	3620 Spencer Hwy.	Pasadena	TX	Terminated
DSH450184BW	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-CAT Scan-Pasadena	3620 Spencer Hwy.	Pasadena	TX	Terminated
DSH450184BX	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-Nuclear Radiology-Pasadena	3620 Spencer Hwy.	Houston	TX	Terminated
DSH450184BY	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-Ultrasound-Pasadena	3620 Spencer Hwy.	Pasadena	TX	Terminated
DSH450184BZ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-Mammography-Pasadena	3620 Spencer Hwy.	Pasadena	TX	Terminated
DSH450184C	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Anesthesia	9250 Pinecroft	The Woodlands	TX	Active
DSH450184CA	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	OPID-Radiology Diagnostic-Pasadena	3620 Spencer Hwy.	Pasadena	TX	Terminated
DSH450184CB	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Nuclear Radiology	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CC	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Non-Invasive Cardiology	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CD	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Radiology Special Procedures	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CE	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Hemodialysis	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CF	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient ER Observation Center	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CG	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Emergency	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CH	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Endoscopy	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CJ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Respiratory Therapy	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CK	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Radiation Therapy	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CL	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Cath Obs Unit	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CM	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Cardiac Cath	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CN	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient MRI	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CP	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient PET/CT	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CQ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient CT	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CR	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Ultrasound	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CS	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast - Outpatient Radiology Diagnostic	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CT	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Mammography	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CU	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Anesthesia	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CV	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient Surgery	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CW	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Outpatient PACU	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CX	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Diagnostic Observation Unit	11800 Astoria Blvd.	Houston	TX	Active
DSH450184CY	Child	DSH	MEMORIAL HERMANN HOSPITAL SYS	Cancer Center / MH Outpatient Imaging-The Woodlands	9200 Pinecroft	The Woodlands	TX	Terminated
DSH450184CZ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands-OPID-PET/CT Scan	9200 Pinecroft, #100	The Woodlands	TX	Active
DSH450184D	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Radiology Diagnostic	9250 Pinecroft	The Woodlands	TX	Active
DSH450184DA	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands-OPID- MRI	9200 Pinecroft, #100	The Woodlands	TX	Active
DSH450184DB	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands-OPID- CT Scan	9200 Pinecroft, #100	The Woodlands	TX	Active
DSH450184DC	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands-OPID- Radiology Ultrasound	9200 Pinecroft, #100	The Woodlands	TX	Active
DSH450184DD	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient-Endoscopy	1635 North Loop West	Houston	TX	Active
DSH450184DE	Child	DSH	MEMORIAL HERMANN HOSPITAL SYS	Memorial Hermann Home Health	920 Frostwood	Houston	TX	Terminated
DSH450184DF	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Sharpstown Clinic	7504 Bissonnet Street, Building T9	Houston	TX	Terminated
DSH450184DH	Child	DSH	MEMORIAL HERMANN HOSPITAL SYS	Pearland Convenient Care Center	16100 South Freeway	Pearland	TX	Terminated
DSH450184DJ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast - Maternal Fetal Medicine	11800 Astoria Blvd.	Houston	TX	Terminated
DSH450184DK	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast - Intravenous Therapy	11920 Astoria Blvd., #100	Houston	TX	Active
DSH450184DL	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Breast Center Outpatient Mammography	9200 Pinecroft, #150	The Woodlands	TX	Active
DSH450184DM	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient MRI	9250 Pinecroft	The Woodlands	TX	Active
DSH450184DN	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient CT	9250 Pinecroft	The Woodlands	TX	Active
DSH450184DP	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Ultrasound	9250 Pinecroft	The Woodlands	TX	Active
DSH450184DQ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital- Outpatient PACU	1635 North Loop West	Houston	TX	Active
DSH450184DR	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - MRI	1635 North Loop West	Houston	TX	Active
DSH450184DS	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient CT	1635 North Loop West	Houston	TX	Active
DSH450184DT	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Mammography	1635 North Loop West	Houston	TX	Active
DSH450184DU	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Rad Spec Projs	1635 North Loop West	Houston	TX	Active
DSH450184DV	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - Outpatient Ultrasound	1635 North Loop West	Houston	TX	Active
DSH450184DW	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Greater Heights Hospital - NW POB imaging	1801 North Loop West	Houston	TX	Terminated
DSH450184DX	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast - Outpatient Wound Care	11914 Astoria Blvd., #210	Houston	TX	Active
DSH450184DY	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southwest - Outpatient imaging Ultrasound	7789 Southwest Freeway, Suite 150	Houston	TX	Active
DSH450184DZ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southwest - Outpatient imaging PET/CT	7789 Southwest Freeway, Suite 150	Houston	TX	Active
DSH450184E	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Radiology-Therapeutic	9250 Pinecroft	The Woodlands	TX	Terminated
DSH450184EA	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Kruse Clinic	400 Park Lane	Pasadena	TX	Terminated
DSH450184EB	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands-Recovery Room	9250 Pinecroft	The Woodlands	TX	Active
DSH450184EC	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands-Outpatient Endoscopy	9250 Pinecroft	The Woodlands	TX	Active
DSH450184ED	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-CT Scan-Bayshore	11476 Space Center Blvd, #200	Houston	TX	Active
DSH450184EE	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Ultrasound-Bayshore	11476 Space Center Blvd, #200	Houston	TX	Active
DSH450184EF	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast-Radiology Diagnostic-Bayshore	11476 Space Center Blvd, #200	Houston	TX	Active
DSH450184EG	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Emergency Room	16100 South Freeway	Pearland	TX	Active
DSH450184EH	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Dialysis	16100 South Freeway	Pearland	TX	Active
DSH450184EJ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland-Outpatient Surgery	16100 South Freeway	Pearland	TX	Active
DSH450184EK	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Electroencephalography	16100 South Freeway	Pearland	TX	Active
DSH450184EL	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Radiology Magnetic Resonance Imaging (MRI)	16100 South Freeway	Pearland	TX	Active
DSH450184EM	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Non-Invasive Cardiology	16100 South Freeway	Pearland	TX	Active
DSH450184EN	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Physical Therapy	16100 South Freeway	Pearland	TX	Active
DSh450184EP	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Respiratory Care	16100 South Freeway	Pearland	TX	Active
DSH450184EQ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Cath Observation Unit	16100 South Freeway	Pearland	TX	Terminated
DSH450184ER	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Cardiac Cath Lab	16100 South Freeway	Pearland	TX	Active
DSH450184ES	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Radiology CAT Scan	16100 South Freeway	Pearland	TX	Active
DSH450184ET	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Nuclear Radiology	16100 South Freeway	Pearland	TX	Active
DSH450184EU	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Radiology Ultrasound	16100 South Freeway	Pearland	TX	Active
DSH450184EV	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Special Procedures	16100 South Freeway	Pearland	TX	Active
DSH450184EW	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Radiology Diagnostic	16100 South Freeway	Pearland	TX	Active
DSH450184EX	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Anesthesia Surgery	16100 South Freeway	Pearland	TX	Active
DSH450184EY	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Endoscopy	16100 South Freeway	Pearland	TX	Active
DSH450184EZ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Post Anesthesia Care Unit	16100 South Freeway	Pearland	TX	Active
DSH450184F	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Radioisotope	9250 Pinecroft	The Woodlands	TX	Active
DSH450184FA	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Spring CCC Outpatient Imaging - MRI - Magnetic Resonance Imaging	7474 North Grand Parkway West	Spring	TX	Active
DSH450184FB	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Spring CCC Outpatient Imaging - Mammography - Mammography	7474 North Grand Parkway West	Spring	TX	Active
DSH450184FC	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Spring CCC Outpatient Imaging - CT Scan	7474 North Grand Parkway West	Spring	TX	Active
DSH450184FD	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Spring CCC Outpatient Imaging - XRay	7474 North Grand Parkway West	Spring	TX	Active
DSH450184FE	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Spring CCC Outpatient Imaging - Ultrasound	7474 North Grand Parkway West	Spring	TX	Active
DSH450184FF	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Spring Convenient Care Center - emergency room	7474 North Grand Parkway West	Spring	TX	Active
DSH450184FG	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast - Bariatric & Wellness	11800 Astoria Blvd.	Houston	TX	Active
DSH450184FH	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Greater Heights OPID - XRay	1431 Studemont Street	Houston	TX	Active
DSH450184FJ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City OPID - X Ray	2555 Gulf Freeway South	League City	TX	Active
DSH450184FK	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Greater Heights OPID - Ultrasound	1431 Studemont Street	Houston	TX	Active
DSH450184FL	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Greater Heights OPID - CT Scan	1431 Studemont Street	Houston	TX	Active
DSH450184FM	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City Breast Center OPID - Mammography	2555 Gulf Freeway South, #300	League City	TX	Active
DSH450184FN	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Greater Heights OPID - Magnetic Resonance Imaging	1431 Studemont Street	Houston	TX	Active
DSH450184FP	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City OPID - Ultrasound	2555 Gulf Freeway South	League City	TX	Active
DSH450184FQ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Greater Heights Convenient Care Center - Emergency Department	1431 Studemont Street	Houston	TX	Active
DSH450184FR	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City OPID - CT Scan	2555 Gulf Freeway South	League City	TX	Active
DSH450184FS	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City Breast Center OPID - Ultrasound	2555 Gulf Freeway South, #300	League City	TX	Active
DSH450184FT	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City Breast Center OPID - Magnetic Resonance Imaging (MRI)	2555 Gulf Freeway South, #300	League City	TX	Terminated
DSH450184FU	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City Convenient Care Center - Emergency Department	2555 Gulf Freeway South	League City	TX	Active
DSH450184FV	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City OPID - MRI	2555 Gulf Freeway South	League City	TX	Active
DSH450184FW	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Greater Heights- Labor and Delivery - Labor and Delivery	1635 North Loop West	Houston	TX	Active
DSH450184FX	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Woodlands- LDRP - labor and delivery	9250 Pinecroft	The Woodlands	TX	Active
DSH450184FY	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast- Labor and Delivery - Labor and Delivery	11800 Astoria Blvd.	Houston	TX	Active
DSH450184FZ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Woodlands- Pre-admit/Holding - Operating Room	9250 Pinecroft	The Woodlands	TX	Active
DSH450184G	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Laboratory	9250 Pinecroft	The Woodlands	TX	Active
DSH450184GA	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast- Clinical Decision Unit - Observation	11800 Astoria Blvd.	Houston	TX	Active
DSH450184GB	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	HVI-CV Pre-Op - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GC	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	HVI- CV Perfusion - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GD	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	HVI- Pre-Admit & Clinics - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GE	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	HVI- CV OR Surgery - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GF	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	HVI- Cardiac and Pulmonary Rehab - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GG	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	HVI- Noninvasive Cardiology - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GH	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	HVI- CV OR PACU - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GJ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Cardiac Cath Lab - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GK	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	HVI- Cath Lab Recovery - Cardiology	7787 Southwest Fwy	Houston	TX	Active
DSH450184GL	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Greater Heights CCC - Sports Medicine and Rehabilitation	1431 Studemont St	Houston	TX	Active
DSH450184GM	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	League City CCC - CT Scan	2555 Gulf Freeway	League City	TX	Active
DSH450184GP	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Mammography	9250 Pinecroft	The Woodlands	TX	Active
DSH450184GQ	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Rehab	9250 Pinecroft	Shenandoah	TX	Terminated
DSH450184GR	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Surgicenter- Post OP	9250 Pinecroft	Shenandoah	TX	Terminated
DSH450184GS	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Pediatrics	9250 Pinecroft	The Woodlands	TX	Active
DSH450184GT	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Greater Heights - Outpatient Rehab (TIRR)	1635 North Loop West	Houston	TX	Active
DSH450184GU	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Pearland - Clinical Decision Unit (CDU)	16100 South Freeway	Pearland	TX	Active
DSH450184GV	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Wound Care	920 Medical Plaza Dr.	The Woodlands	TX	Active
DSH450184GW	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Southeast - Medication Therapy and Wellness Clinic	11920 Astoria Blvd	Houston	TX	Active
DSH450184GX	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	Memorial Hermann Southwest Hospital - Medication Therapy and Wellness Clinic	7737 Southwest Fwy	Houston	TX	Active
DSH450184H	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Respiratory Therapy	9250 Pinecroft	The Woodlands	TX	Active
DSH450184J	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Physical Therapy	9250 Pinecroft	The Woodlands	TX	Terminated
DSH450184K	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Electrocardiology	9250 Pinecroft	The Woodlands	TX	Active
DSH450184L	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Renal Dialysis	9250 Pinecroft	The Woodlands	TX	Active
DSH450184M	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Cardiac Cath	9250 Pinecroft	The Woodlands	TX	Active
DSH450184N	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Electroencephalography	9250 Pinecroft	The Woodlands	TX	Active
DSH450184P	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Diabetes Education	9250 Pinecroft	The Woodlands	TX	Active
DSH450184Q	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Observation Beds (Not-Distinct)	9250 Pinecroft	Shenandoah	TX	Terminated
DSH450184R	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Chest Pain Obs / Express Admit	9250 Pinecroft	The Woodlands	TX	Active
DSH450184S	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Infusion Suite	9250 Pinecroft	The Woodlands	TX	Active
DSH450184T	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Radiation Oncology Center	920 Medical Plaza Drive, #100	Shenandoah	TX	Terminated
DSH450184U	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Emergency	9250 Pinecroft	The Woodlands	TX	Active
DSH450184V	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Outpatient Orthopedic and Sports Medicine	9250 Pinecroft	The Woodlands	TX	Terminated
DSH450184X	Child	DSH	MEMORIAL HERMANN HOSPITAL SYSTEM	The Woodlands - Breast Center Ultrasound	9200 Pinecroft, #150	The Woodlands	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 8:17:14 AM	9/5/2024 2:00:10 PM	9/5/2024 2:00 PM
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	9/14/2022 11:40:12 AM	9/6/2023 8:17:14 AM	9/6/2023 8:17 AM
Details	Last Recertification Date	Update	Recertification	9/8/2021 4:17:46 PM	9/14/2022 11:40:12 AM	9/14/2022 11:40 AM
Details	Last Recertification Date	Update	Recertification	9/12/2020 6:35:03 PM	9/8/2021 4:17:46 PM	9/8/2021 4:17 PM
Contacts	Primary Contact	Update	Change Request	Rangel, Illiana 340B Manager Memorial Hermann 7132422858	Wucki, Eric John 340B Manager Memorial Hermann 2625272475	5/21/2021 4:41 PM
Contacts	Authorizing Official	Update	AO Change Request	Tucker, Rebecca VP, Finance Memorial Hermann System 7134565340	Ogden, Robert C Associate Vice President of Finance Memorial Hermann 7134565111	11/16/2020 6:34 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1730132234 ( )		9/12/2020 6:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1730132234	9/12/2020 6:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/12/2020 6:35 PM
Details	Last Recertification Date	Update	Recertification		9/12/2020 6:35:03 PM	9/12/2020 6:35 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		Tucker, Rebecca VP, Finance Memorial Hermann System 7134565340	11/19/2019 1:43 PM
Details	340B ID	Update	New Registration		DSH450184GB	11/19/2019 1:43 PM
Details	Entity Name	Update	New Registration	MEMORIAL HERMANN HOSPITAL SYS	MEMORIAL HERMANN HOSPITAL SYSTEM	11/19/2019 1:43 PM
Details	Entity Subname	Update	New Registration	HVI-CV Pre-Op	HVI-CV Pre-Op - Cardiology	11/19/2019 1:43 PM
Dates	Participating Approval Date	Update	New Registration		11/19/2019 1:43:13 PM	11/19/2019 1:43 PM
Details	State	Update	New Registration	Pending	Approved	11/19/2019 1:43 PM
Dates	Signed By Date	Update	New Registration		10/14/2019 3:01:22 PM	11/19/2019 1:43 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	11/19/2019 1:43 PM
Addresses	Main Address	Insert	New Registration		7787 Southwest Fwy Houston, TX 77074	10/11/2019 9:59 PM
Addresses	Billing Address	Insert	New Registration		Memorial Hermann 929 Gessner Rd, Suite 2690 Houston, TX 77024	10/11/2019 9:59 PM
Addresses	Shipping Address	Insert	New Registration		Memorial Hermann 7600 Beechnut Houston, TX 77074	10/11/2019 9:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/11/2019 9:59 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		020834001	10/11/2019 9:59 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	10/11/2019 9:59 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1730132234	10/11/2019 9:59 PM
Contacts	Authorizing Official	Insert	New Registration		Tucker, Rebecca VP, Finance Memorial Hermann System 7134565340	10/11/2019 9:59 PM
Contacts	Primary Contact	Insert	New Registration		Rangel, Illiana 340B Manager Memorial Hermann 7132422858	10/11/2019 9:59 PM
Details	Last Recertification Date	Insert	New Registration			10/11/2019 9:59 PM
Details	Grant Number	Insert	New Registration			10/11/2019 9:59 PM
Details	340B ID	Insert	New Registration			10/11/2019 9:59 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2019 9:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2019 9:59 PM
Details	Medicare Provider Number	Insert	New Registration		450184	10/11/2019 9:59 PM
Details	Entity Name	Insert	New Registration		MEMORIAL HERMANN HOSPITAL SYS	10/11/2019 9:59 PM
Details	Program Code	Insert	New Registration		DSH	10/11/2019 9:59 PM
Details	Entity Subname	Insert	New Registration		HVI-CV Pre-Op	10/11/2019 9:59 PM
Dates	Participating Approval Date	Insert	New Registration			10/11/2019 9:59 PM
Details	State	Insert	New Registration		Pending	10/11/2019 9:59 PM
Dates	Registration Date	Insert	New Registration		10/11/2019 9:59:27 PM	10/11/2019 9:59 PM
Dates	Signed By Date	Insert	New Registration			10/11/2019 9:59 PM
Dates	Start Date	Insert	New Registration			10/11/2019 9:59 PM
Terminations	Termination Comments	Insert	New Registration			10/11/2019 9:59 PM
Terminations	Termination Date	Insert	New Registration			10/11/2019 9:59 PM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2019 9:59 PM
Terminations	Termination Reason	Insert	New Registration			10/11/2019 9:59 PM