Covered Entity Details

PED453301-10 Driscoll Children's Hospital (Active) - information as of 6/9/2025 11:00:51 PM

Main Details

Name

Driscoll Children's Hospital

Subdivision Name

CPSST NEPHRO- LAREDO - CPSST NEPHROLOGY - LAREDO

Type

Children's Hospital

Rural

340B ID

PED453301-10

Medicare Provider Number

453301

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/14/2020

Participating Start Date

7/1/2020

Participating Approval Date

6/5/2020

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Driscoll Children's Hospital
Steven Eric King, CFO
(361) 694-5934

Primary Contact

Driscoll Children's Hospital
Jessy Varkey Thomas, Director of Pharmacy
(361) 694-5061

Addresses

Street Address

7210 McPherson Road
Building A
Suite # 104
Laredo, TX 78041

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	132812205,132812206,17425777467005	1548286172,1326638479

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
PED453301-01	Child	PED	Driscoll Children's Hospital	Satellite Clinic Harlingen	2121 Pease St. #604	Harlingen	TX	Terminated
PED453301-02	Child	PED	Driscoll Children's Hospital	Satellite Clinic McAllen	1120 EAST RIDGE ROAD	MCALLEN	TX	Terminated
PED453301-03	Child	PED	Driscoll Children's Hospital	Satellite Clinic Victoria	115 MEDICAL DRIVE, SUITE 201	VICTORIA	TX	Terminated
PED453301-04	Child	PED	Driscoll Children's Hospital	Satellite Clinic Brownsville	5500 NORTH EXPRESSWAY	BROWNSVILLE	TX	Terminated
PED453301-05	Child	PED	Driscoll Children's Hospital	Satellite Clinic Laredo	10710 McPherson Ave. Suite 202	Laredo	TX	Terminated
PED453301-06	Child	PED	Driscoll Children's Hospital	QUICK CARE-SARATOGA	5945 Saratoga Boulevard	Corpus Christi	TX	Active
PED453301-07	Child	PED	Driscoll Children's Hospital	CPSST GASTRO- LAREDO - CPSST GASTROENTEROLOGY - LAREDO	7210 McPherson Road	Laredo	TX	Active
PED453301-08	Child	PED	Driscoll Children's Hospital	CPSST ENDOC - LAREDO - CPSST ENDOCRINOLOGY - LAREDO	7210 McPherson Road	Laredo	TX	Active
PED453301-09	Child	PED	Driscoll Children's Hospital	CPSST UROLOGY LAR - CPSST UROLOGY - LAREDO	7210 McPherson Road	Laredo	TX	Active
PED453301-10	Child	PED	Driscoll Children's Hospital	CPSST NEPHRO- LAREDO - CPSST NEPHROLOGY - LAREDO	7210 McPherson Road	Laredo	TX	Active
PED453301-11	Child	PED	Driscoll Children's Hospital	CPSST PULMO- LAREDO - CPSST PULMONOLOGY - LAREDO	7210 McPherson Road	Laredo	TX	Active
PED453301-12	Child	PED	Driscoll Children's Hospital	DCH Dialysis - MCALLEN - DCH Dialysis Clinic	1120 East Ridge Road	McAllen	TX	Active
PED453301-13	Child	PED	Driscoll Children's Hospital	CPSST NEPHRO - MCALLEN - CPSST NEPHROLOGY - MCALLEN	1120 East Ridge Road	McAllen	TX	Active
PED453301-14	Child	PED	Driscoll Children's Hospital	CPSST RHEUMA MCALLEN - CPSST RHEUMATOLOGY MCALLEN	1120 East Ridge Road	McAllen	TX	Active
PED453301-15	Child	PED	Driscoll Children's Hospital	CPSST HEM ONC-MCAL - CPSST HEMATOLOGY ONCOLOGY - MCALLEN	1120 East Ridge Road	McAllen	TX	Active
PED453301-16	Child	PED	Driscoll Children's Hospital	CPSST SURG- VICTORIA - CPSST SURGERY - VICTORIA	106 Springwood Drive	VICTORIA	TX	Active
PED453301-17	Child	PED	Driscoll Children's Hospital	CPSST GASTRO- BROWNS - CPSST GASTROENTEROLOGY - BROWNSVILLE	5500 NORTH EXPRESSWAY 77	BROWNSVILLE	TX	Active
PED453301-18	Child	PED	Driscoll Children's Hospital	CPSST NEPHRO- BROWNS - CPSST NEPHROLOGY - BROWNSVILLE	5500 NORTH EXPRESSWAY 77	BROWNSVILLE	TX	Active
PED453301-19	Child	PED	Driscoll Children's Hospital	CPSST HEM ONC- BRO - CPSST HEMATOLOGY ONCOLOGY - BROWNSVILLE	5500 NORTH EXPRESSWAY 77	BROWNSVILLE	TX	Active
PED453301-20	Child	PED	Driscoll Children's Hospital	CPSST ORTHO CL MCA - ORTHOPEDIC CLINIC - McAllen	1120 E. Ridge Road	McAllen	TX	Active
PED453301-21	Child	PED	Driscoll Children's Hospital	CPSST ORTHO CL BRO - ORTHOPEDIC CLINIC - Brownsville	5500 North Expressway 77	Brownsville	TX	Active
PED453301-22	Child	PED	Driscoll Children's Hospital	CPSST SURG- LAREDO - Surgical Clinic - Laredo	7210 McPherson Road	Laredo	TX	Active
PED453301-23	Child	PED	Driscoll Children's Hospital	CPSST SURGERY - MCALLEN - Surgical Clinic - McAllen	1120 E. Ridge Road	McAllen	TX	Terminated
PED453301-24	Child	PED	Driscoll Children's Hospital	RAD X-RAY BROWNSVILLE - Radiology X-Ray Brownsville	5500 North Expressway 77	Brownsville	TX	Active
PED453301-25	Child	PED	Driscoll Children's Hospital	RAD X-RAY MCALLEN - Radiology X-Ray McAllen	1120 E. Ridge Road	McAllen	TX	Active
PED453301-26	Child	PED	Driscoll Children's Hospital	CPSST GASTRO - VICTORIA - Gastroenterology - Victoria	106 Springwood Drive	Victoria	TX	Active
PED453301-27	Child	PED	Driscoll Children's Hospital	CPSST SURG- HARLINGEN - Surgical Clinic - Harlingen	2121 Pease Street	Harlingen	TX	Terminated
PED453301-28	Child	PED	Driscoll Children's Hospital	CPSST SURG- BROWNS - Surgical Clinic - Brownsville	5500 North Expressway 77	Brownsville	TX	Active
PED453301-29	Child	PED	Driscoll Children's Hospital	CPSST PULMO- BRO - Pulmonology Clinic - Brownsville	5500 North Expressway 77	Brownsville	TX	Active
PED453301-30	Child	PED	Driscoll Children's Hospital	RAD NM MCALLEN - Radiology Nuclear Medicine - McAllen	1120 E. Ridge Road	McAllen	TX	Active
PED453301-31	Child	PED	Driscoll Children's Hospital	DRISCOLL CHILDRENS HOSPITAL - CPSST NEUROLOGY - BROWNSVILLE	5500 NORTH EXPRESSWAY 77	BROWNSVILLE	TX	Active
PED453301-32	Child	PED	Driscoll Children's Hospital	DRISCOLL CHILDRENS HOSPITAL - CPSST NEUROLOGY - MCALLEN	1120 EAST RIDGE ROAD	MCALLEN	TX	Active
PED453301-33	Child	PED	Driscoll Children's Hospital	CPSST Urology - Brownsville - CPSST Urology - Brownsville	5500 N. Expressway 77	Brownsville	TX	Active
PED453301-34	Child	PED	Driscoll Children's Hospital	CPSST Pulmonology - Victoria - CPSST Pulmonology - Victoria	106 Springwood Drive	Victoria	TX	Active
PED453301-35	Child	PED	Driscoll Children's Hospital	CPSST Neurology - Laredo - CPSST Neurology - Laredo	7210 McPherson Road	Laredo	TX	Active
PED453301-36	Child	PED	Driscoll Children's Hospital	CPSST Urology - Victoria - CPSST Urology - Victoria	106 Springwood Drive	Victoria	TX	Active
PED453301-37	Child	PED	Driscoll Children's Hospital	CPSST Plastics - Brownsville - CPSST Plastics - Brownsville	5500 N. Expressway 77	Brownsville	TX	Active
PED453301-38	Child	PED	Driscoll Children's Hospital	CPSST Plastics - McAllen - CPSST Plastics - McAllen	1120 E. Ridge Road	McAllen	TX	Active
PED453301-39	Child	PED	Driscoll Children's Hospital	CPSST Neurology - Victoria - CPSST Neurology - Victoria	106 Springwood Drive	Victoria	TX	Active
PED453301-40	Child	PED	Driscoll Children's Hospital	CPSST Nephrology - Victoria - CPSST Nephrology - Victoria	106 Springwood Drive	VIctoria	TX	Active
PED453301-41	Child	PED	Driscoll Children's Hospital	CPSST Plastics - Laredo - CPSST Plastics - Laredo	17210 McPherson Road	Laredo	TX	Terminated
PED453301-42	Child	PED	Driscoll Children's Hospital	CPSST Diabetes - Brownsville - CPSST Diabetes - Brownsville	5500 N. Expressway 77	Brownsville	TX	Active
PED453301-43	Child	PED	Driscoll Children's Hospital	CPSST Endocrinology - Brownsville - CPSST Endocrinology - Brownsville	5500 N Expressway 77	Brownsville	TX	Active
PED453301-44	Child	PED	Driscoll Children's Hospital	CPSST Neurosurgery - Brownsville - CPSST Neurosurgery - Brownsville	5500 N Expressway 77	Brownsville	TX	Active
PED453301-45	Child	PED	Driscoll Children's Hospital	CPSST Rheumatology - Brownsville - CPSST Rheumatology - Brownsville	5500 N Expressway 77	Brownsville	TX	Active
PED453301-46	Child	PED	Driscoll Children's Hospital	CPSST Endocrinology - McAllen - CPSST Endocrinology - McAllen	1120 E Ridge Rd	McAllen	TX	Active
PED453301-47	Child	PED	Driscoll Children's Hospital	CPSST Neurosurgery - McAllen - CPSST Neurosurgery - McAllen	1120 E Ridge Rd	McAllen	TX	Active
PED453301-48	Child	PED	Driscoll Children's Hospital	CPSST Orthopedics - Laredo - CPSST Orthopedics - Laredo	7210 McPherson Rd	Laredo	TX	Active
PED453301-49	Child	PED	Driscoll Children's Hospital	CPSST Pediatric Sleep Clinic Laredo - CPSST Pediatric Sleep Clinic Laredo	7210 McPherson Rd	Laredo	TX	Approved
PED453301-50	Child	PED	Driscoll Children's Hospital	CPSST Diabetes McAllen - CPSST Diabetes McAllen	1120 E. Ridge Rd	McAllen	TX	Approved
PED453301-51	Child	PED	Driscoll Children's Hospital	Morgan Quick Care Clinic - Morgan Quick Care Clinic	2401 Morgan Ave.	Corpus Christi	TX	Approved
PED453301-52	Child	PED	Driscoll Children's Hospital	CPSST Ortho Clinic Victoria - CPSST Ortho Clinic Victoria	106 Springwood Dr	Victoria	TX	Approved
PED453301-53	Child	PED	Driscoll Children's Hospital	CPSST Endocrinology Victoria - CPSST Endocrinology Victoria	106 Springwood Dr.	Victoria	TX	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/31/2023 4:36:44 PM	8/22/2024 9:11:32 AM	8/22/2024 9:11 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 9:19:33 AM	8/31/2023 4:36:44 PM	8/31/2023 4:36 PM
Addresses	Main Address	Update	Change Request	17210 McPherson Road Building A Suite # 104 Laredo, TX 78041	7210 McPherson Road Building A Suite # 104 Laredo, TX 78041	2/23/2023 9:33 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 8:41:38 AM	8/30/2022 9:19:33 AM	8/30/2022 9:19 AM
Addresses	Main Address	Update	Change Request	10710 McPherson Ave Laredo, TX 78041	17210 McPherson Road Building A Suite # 104 Laredo, TX 78041	4/14/2022 2:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/12/2021 8:26 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		17425777467005	10/12/2021 8:26 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	10/12/2021 8:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1326638479	8/24/2021 8:41 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/24/2021 8:41 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 12:58:47 PM	8/24/2021 8:41:38 AM	8/24/2021 8:41 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1548286172 ( )		9/8/2020 12:58 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548286172	9/8/2020 12:58 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/8/2020 12:58 PM
Details	Last Recertification Date	Update	Recertification		9/8/2020 12:58:47 PM	9/8/2020 12:58 PM
Contacts	Authorizing Official	Update	Change Request	Ward, Greg VP Finance Driscoll Children's Hospital 3616946126	King, Steven Eric CFO Driscoll Children's Hospital 3616945934	8/17/2020 10:05 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		Ward, Greg VP Finance Driscoll Children's Hospital 3616946126	6/5/2020 9:14 AM
Details	340B ID	Update	New Registration		PED453301-10	6/5/2020 9:14 AM
Details	Entity Name	Update	New Registration	DRISCOLL CHILDRENS HOSPITAL	Driscoll Children's Hospital	6/5/2020 9:14 AM
Details	Entity Subname	Update	New Registration	CPSST NEPHRO- LAREDO	CPSST NEPHRO- LAREDO - CPSST NEPHROLOGY - LAREDO	6/5/2020 9:14 AM
Dates	Participating Approval Date	Update	New Registration		6/5/2020 9:14:37 AM	6/5/2020 9:14 AM
Details	State	Update	New Registration	Pending	Approved	6/5/2020 9:14 AM
Dates	Signed By Date	Update	New Registration		4/15/2020 1:01:32 PM	6/5/2020 9:14 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	6/5/2020 9:14 AM
Addresses	Main Address	Insert	New Registration		10710 McPherson Ave Laredo, TX 78041	4/14/2020 7:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2020 7:06 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		132812205	4/14/2020 7:06 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/14/2020 7:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2020 7:06 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		132812206	4/14/2020 7:06 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/14/2020 7:06 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548286172	4/14/2020 7:06 PM
Contacts	Authorizing Official	Insert	New Registration		Ward, Greg VP Finance Driscoll Children's Hospital 3616946126	4/14/2020 7:06 PM
Contacts	Primary Contact	Insert	New Registration		Thomas, Jessy Varkey Director of Pharmacy Driscoll Children's Hospital 3616945061	4/14/2020 7:06 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2020 7:06 PM
Details	Grant Number	Insert	New Registration			4/14/2020 7:06 PM
Details	340B ID	Insert	New Registration			4/14/2020 7:06 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2020 7:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2020 7:06 PM
Details	Medicare Provider Number	Insert	New Registration		453301	4/14/2020 7:06 PM
Details	Entity Name	Insert	New Registration		DRISCOLL CHILDRENS HOSPITAL	4/14/2020 7:06 PM
Details	Program Code	Insert	New Registration		PED	4/14/2020 7:06 PM
Details	Entity Subname	Insert	New Registration		CPSST NEPHRO- LAREDO	4/14/2020 7:06 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2020 7:06 PM
Details	State	Insert	New Registration		Pending	4/14/2020 7:06 PM
Dates	Registration Date	Insert	New Registration		4/14/2020 7:06:27 PM	4/14/2020 7:06 PM
Dates	Signed By Date	Insert	New Registration			4/14/2020 7:06 PM
Dates	Start Date	Insert	New Registration			4/14/2020 7:06 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2020 7:06 PM
Terminations	Termination Date	Insert	New Registration			4/14/2020 7:06 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2020 7:06 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2020 7:06 PM