Covered Entity Details

DSH450431BA ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER (Active) - information as of 4/29/2025 10:35:49 PM

Main Details

Name

ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER

Subdivision Name

St Davids Rehabilitation - Lake Air

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450431BA

Medicare Provider Number

450431

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

3/27/2020

Participating Start Date

4/1/2020

Participating Approval Date

4/1/2020

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

St. David's Healthcare
David McKnight, CFO
(512) 544-5030

Primary Contact

St. David's Healthcare
JOSEPHINE FUENTES, 340B Program Coordinator
(512) 681-2136

Addresses

Street Address

2423 Williams Dr
Georgetown, TX 78626

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
TX	094160103,094160101	1720033947

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
DSH450431A	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	HEART HOSPITAL OF AUSTIN A CAMPUS OF ST DAVID'S MEDICAL CENTER	3801 N LAMAR	AUSTIN	TX	Terminated
DSH450431AA	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Ultrasound	3801 N Lamar Blvd	Austin	TX	Active
DSH450431AB	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - MRI	3801 N Lamar Blvd	Austin	TX	Active
DSH450431AC	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Labor/Delivery	2000 Scenic Dr.	Georgetown	TX	Active
DSH450431AD	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Nuclear Medicine	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AE	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Mammography	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AF	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St. Davids Georgetown Hospital - Anesthesia	2000 Scenic Dr.	Georgetown	TX	Active
DSH450431AG	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - CT Scan	2000 Scenic Dr.	Georgetown	TX	Active
DSH450431AH	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Hemodialysis	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AJ	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Surgery	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AK	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Speech Pathology	2000 Scenic Dr.	Georgetown	TX	Active
DSH450431AL	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St. Davids Georgetown Hospital - Recovery Room	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AM	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Emergency Department	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AN	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Pathology	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AP	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Rehabilitation - Sun City	400 Del Webb Blvd	Georgetown	TX	Active
DSH450431AQ	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Endoscopy	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AR	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Occupational Therapy	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AS	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Ultrasound	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AT	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - ECHO	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AU	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St. Davids Georgetown Hospital - Cardiac Rehabilitation	2000 Scenic Dr.	Georgetown	TX	Active
DSH450431AV	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Physical Therapy	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AW	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St. David's Georgetown Hospital - Operating Room	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AX	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - EKG	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AY	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - MRI	2000 Scenic Dr	Georgetown	TX	Active
DSH450431AZ	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Respiratory Therapy	2000 Scenic Dr	Georgetown	TX	Active
DSH450431B	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	CARDIOVASCULAR IMAGING CENTER	2200 PARK BEND DRIVE	AUSTIN	TX	Active
DSH450431BA	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Rehabilitation - Lake Air	2423 Williams Dr	Georgetown	TX	Active
DSH450431BB	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St Davids Georgetown Hospital - Radiology Diagnostic	2000 Scenic Dr	Georgetown	TX	Active
DSH450431BC	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Pathology	3801 N Lamar Blvd	Austin	TX	Active
DSH450431BD	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Physical	3801 N Lamar Blvd	Austin	TX	Active
DSH450431BE	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - EP	3801 N Lamar Blvd	Austin	TX	Active
DSH450431BF	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Laboratory	3801 N Lamar Blvd	Austin	TX	Active
DSH450431BG	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - EKG	3801 N Lamar Blvd	Austin	TX	Active
DSH450431BH	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St. David's Georgetown Hospital - Laboratory	2000 Scenic Drive	Georgetown	TX	Active
DSH450431BJ	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St. David's - Spine and Sports Therapy	3000 N IH 35	Austin	TX	Active
DSH450431C	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	CARDIOVASCULAR IMAGING CENTER	4316 JAMES CASEY STREET	AUSTIN	TX	Active
DSH450431D	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	CARDIOVASCULAR IMAGING CENTER	1015 EAST 32ND STREET	AUSTIN	TX	Active
DSH450431E	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	CARDIOVASCULAR IMAGING CENTER	1330 WONDER WORLD DRIVE	SAN MARCOS	TX	Active
DSH450431F	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	CARDIOVASCULAR IMAGING CENTER	2559 WESTERN TRAILS BLVD.	AUSTIN	TX	Active
DSH450431G	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	CARDIOVASCULAR IMAGING CENTER	3801 N. LAMAR BOULEVARD	AUSTIN	TX	Active
DSH450431H	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Hemodialysis	3801 N Lamar Blvd	Austin	TX	Active
DSH450431J	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - GI Lab	3801 N Lamar Blvd	Austin	TX	Active
DSH450431K	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Cat Scan	3801 N Lamar Blvd	Austin	TX	Active
DSH450431L	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Day Patient	3801 N Lamar Blvd	Austin	TX	Active
DSH450431M	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Sleep Lab	3801 N Lamar Blvd	Austin	TX	Active
DSH450431N	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - ICU	3801 N Lamar Blvd	Austin	TX	Active
DSH450431P	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Emergency Department	3801 N Lamar Blvd	Austin	TX	Active
DSH450431Q	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Cath Lab	3801 N Lamar Blvd	Austin	TX	Active
DSH450431R	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Surgery	3801 N Lamar Blvd	Austin	TX	Active
DSH450431S	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Executive Wellness	3801 N Lamar Blvd	Austin	TX	Active
DSH450431T	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Nuclear Medicine	3801 N Lamar Blvd	Austin	TX	Active
DSH450431U	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Respiratory Therapy	3801 N Lamar Blvd	Austin	TX	Active
DSH450431V	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Anesthesia	3801 N Lamar Blvd	Austin	TX	Active
DSH450431W	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - Radiology	3801 N Lamar Blvd	Austin	TX	Active
DSH450431X	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - PCU	3801 N Lamar Blvd	Austin	TX	Active
DSH450431Y	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	St. David's Wound Care/HBO - Wound Care/HBO	900 E. 30th Street	Austin	TX	Terminated
DSH450431Z	Child	DSH	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	Heart Hospital of Austin - PACU	3801 N Lamar Blvd	Austin	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 5:10:04 PM	9/5/2024 4:10:16 PM	9/5/2024 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/1/2023 2:11 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		094160101	12/1/2023 2:11 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		TX	12/1/2023 2:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720033947 (MS)		12/1/2023 2:11 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1720033947 (LA)		12/1/2023 2:11 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1708330 (LA)		9/15/2023 9:41 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	03283068 (MS)		9/15/2023 9:41 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 5:38:33 PM	9/5/2023 5:10:04 PM	9/5/2023 5:10 PM
Contacts	Primary Contact	Update	PC Change Request	Patrick, Tristan Clinical Pharmacy Manager St. David's Georgetown 5129424191	FUENTES, JOSEPHINE 340B Program Coordinator St. David's Healthcare 5126812136	6/1/2023 6:24 AM
Contacts	Authorizing Official	Update	AO Change Request	Stutts, Miah B CFO St. David's Medical Center 5125445030	McKnight, David CFO St. David's Healthcare 5125445030	5/5/2023 5:56 AM
Contacts	Primary Contact	Update	Group Change Request	Blanco, Marvin Division 340B Program Manager St. David's Healthcare 5126812136	Patrick, Tristan Clinical Pharmacy Manager St. David's Georgetown 5129424191	11/28/2022 1:55 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 3:27:14 PM	9/13/2022 5:38:33 PM	9/13/2022 5:38 PM
Contacts	Authorizing Official	Update	Change Request	Steward, Todd CEO St Davids Medical Center 5125444215	Stutts, Miah B CFO St. David's Medical Center 5125445030	3/16/2022 8:34 AM
Contacts	Primary Contact	Update	Profile Change Request	Blanco, Marvin Market 340B Manager St. David's Healthcare 5126812136	Blanco, Marvin Division 340B Program Manager St. David's Healthcare 5126812136	2/10/2022 5:37 PM
Details	Last Recertification Date	Update	Recertification	8/28/2020 8:41:03 AM	8/16/2021 3:27:14 PM	8/16/2021 3:27 PM
Contacts	Primary Contact	Update	Profile Change Request	Blanco, Marvin Market 340B Coordinator St. David's Healthcare 5126812136	Blanco, Marvin Market 340B Manager St. David's Healthcare 5126812136	5/11/2021 8:57 AM
Contacts	Primary Contact	Update	Change Request	Jamali, Rabia Pharmacy Operations Manager St. David's Medical Center 5125448574	Blanco, Marvin Market 340B Coordinator St. David's Healthcare 5126812136	1/29/2021 3:00 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1720033947 ( )		8/28/2020 8:41 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1720033947	8/28/2020 8:41 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/28/2020 8:41 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1720033947	8/28/2020 8:41 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/28/2020 8:41 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1720033947	8/28/2020 8:41 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/28/2020 8:41 AM
Details	Last Recertification Date	Update	Recertification		8/28/2020 8:41:03 AM	8/28/2020 8:41 AM
Details	Entity Subname	Update	Recertification	St Davids Rebabilitation- Lake Air - Rehabilitation	St Davids Rehabilitation - Lake Air	8/28/2020 8:41 AM
Contacts	Authorizing Official	Update	Change Request	Huffine, Daniel CFO St. David's Medical Center 5125445030	Steward, Todd CEO St Davids Medical Center 5125444215	5/29/2020 11:32 AM
Details	State	Update	OPA Edit	Approved	Active	4/2/2020 6:08 AM
Dates	Start Date	Update	OPA Edit	7/1/2020 12:00:00 AM	4/1/2020 12:00:00 AM	4/2/2020 6:08 AM
Contacts	Signed By	Insert	New Registration		Huffine, Daniel CFO St. David's Medical Center 5125445030	4/1/2020 9:07 AM
Details	340B ID	Update	New Registration		DSH450431BA	4/1/2020 9:07 AM
Details	Entity Name	Update	New Registration	ST. DAVIDS MEDICAL CENTER	ST. DAVID'S HEALTHCARE PARTNERSHIP, L.P., LLP, DBA ST. DAVID'S MEDICAL CENTER	4/1/2020 9:07 AM
Details	Entity Subname	Update	New Registration	St Davids Rebabilitation- Lake Air	St Davids Rebabilitation- Lake Air - Rehabilitation	4/1/2020 9:07 AM
Dates	Participating Approval Date	Update	New Registration		4/1/2020 9:07:47 AM	4/1/2020 9:07 AM
Details	State	Update	New Registration	Pending	Approved	4/1/2020 9:07 AM
Dates	Signed By Date	Update	New Registration		3/31/2020 3:01:27 PM	4/1/2020 9:07 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/1/2020 9:07 AM
Addresses	Main Address	Insert	New Registration		2423 Williams Dr Georgetown, TX 78626	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		094160103	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1708330	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03283068	3/27/2020 2:21 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	3/27/2020 2:21 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1720033947	3/27/2020 2:21 PM
Contacts	Authorizing Official	Insert	New Registration		Huffine, Daniel CFO St. David's Medical Center 5125445030	3/27/2020 2:21 PM
Contacts	Primary Contact	Insert	New Registration		Jamali, Rabia Pharmacy Operations Manager St. David's Medical Center 5125448574	3/27/2020 2:21 PM
Details	Last Recertification Date	Insert	New Registration			3/27/2020 2:21 PM
Details	Grant Number	Insert	New Registration			3/27/2020 2:21 PM
Details	340B ID	Insert	New Registration			3/27/2020 2:21 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			3/27/2020 2:21 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			3/27/2020 2:21 PM
Details	Medicare Provider Number	Insert	New Registration		450431	3/27/2020 2:21 PM
Details	Entity Name	Insert	New Registration		ST. DAVIDS MEDICAL CENTER	3/27/2020 2:21 PM
Details	Program Code	Insert	New Registration		DSH	3/27/2020 2:21 PM
Details	Entity Subname	Insert	New Registration		St Davids Rebabilitation- Lake Air	3/27/2020 2:21 PM
Dates	Participating Approval Date	Insert	New Registration			3/27/2020 2:21 PM
Details	State	Insert	New Registration		Pending	3/27/2020 2:21 PM
Dates	Registration Date	Insert	New Registration		3/27/2020 2:21:21 PM	3/27/2020 2:21 PM
Dates	Signed By Date	Insert	New Registration			3/27/2020 2:21 PM
Dates	Start Date	Insert	New Registration			3/27/2020 2:21 PM
Terminations	Termination Comments	Insert	New Registration			3/27/2020 2:21 PM
Terminations	Termination Date	Insert	New Registration			3/27/2020 2:21 PM
Terminations	Termination Effective Date	Insert	New Registration			3/27/2020 2:21 PM
Terminations	Termination Reason	Insert	New Registration			3/27/2020 2:21 PM