Covered Entity Details

PED193300-34 Children's Hospital (Active) - information as of 5/9/2025 10:48:09 PM

Main Details

Name

Children's Hospital

Subdivision Name

Clinic - Specialty - Westbank

Type

Children's Hospital

Rural

340B ID

PED193300-34

Medicare Provider Number

193300

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/13/2021

Participating Start Date

1/1/2022

Participating Approval Date

11/8/2021

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

Children's Hospital
Lucio A. Fragoso, President & CEO
(504) 896-9452

Primary Contact

Children's Hospital
Lindy C Bosworth, Director of Pharmacy
(504) 894-6764

Addresses

Street Address

829 BARATARIA BLVD
MARRERO, LA 70072-1839

Billing Address

Children's Hospital
200 Henry Clay Ave
New Orleans, LA 70118

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
LA	1734489	1104819366

Shipping Addresses

Shipping Address 1

Children's Hospital
200 Henry Clay Ave
New Orleans, LA 70118

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
PED193300-01	Child	PED	Children's Hospital	Clinic - Specialty - Metairie	3040 33RD STREET	METAIRIE	LA	Active
PED193300-04	Child	PED	Children's Hospital	CHMPC Tulane Clinic	4740 S. I-10 SERVICE ROAD	METAIRIE	LA	Active
PED193300-06	Child	PED	Children's Hospital	CHMPC Metairie Pediatric Clinic	2201 VETERANS BLVD	METAIRIE	LA	Active
PED193300-07	Child	PED	Children's Hospital	NAPOLEON PEDIATRICS	2633 Napoleon Avenue	NEW ORLEANS	LA	Terminated
PED193300-09	Child	PED	Children's Hospital	KIDS FIRST TIGER CARE	1661 CANAL STREET	NEW ORLEANS	LA	Terminated
PED193300-10	Child	PED	Children's Hospital	PHYSICIANS OF RIVER RIDGE	9605 JEFFERSON HWY	RIVER RIDGE	LA	Terminated
PED193300-11	Child	PED	Children's Hospital	NORTHLAKE PEDIATRICS	728 W. 11TH STREET	COVINGTON	LA	Terminated
PED193300-12	Child	PED	Children's Hospital	CHMPC Pelican Pediatric Clinic	3100 KINGMAN STREET	METAIRIE	LA	Active
PED193300-13	Child	PED	Children's Hospital	PELICAN PEDIATRIC PHYSICIANS	501 RUE DE SANTE	LAPLACE	LA	Terminated
PED193300-15	Child	PED	Children's Hospital	CHILDREN'S HOSPITAL DIALYSIS UNIT	200 HENRY CLAY AVENUE	NEW ORLEANS	LA	Terminated
PED193300-20	Child	PED	Children's Hospital	CHMPC Westbank Marrero Clinic	829 Barataria Blvd	Marrero	LA	Active
PED193300-21	Child	PED	Children's Hospital	Hematology Oncology Clinic	200 Henry Clay Avenue	New Orleans	LA	Terminated
PED193300-22	Child	PED	Children's Hospital	CHILDRENS HOSPITAL INC - Kids First Tiger Care	2633 NAPOLEAN AVENUE SUITE 707	NEW ORLEANS	LA	Terminated
PED193300-23	Child	PED	Children's Hospital	Clinic - Ridgelake - Metairie	2121 RIDGELAKE DR	METAIRIE	LA	Active
PED193300-24	Child	PED	Children's Hospital	CHMPC Northlake Pediatric Clinic	5025 KEYSTONE BLVD-FIRST FLOOR	COVINGTON	LA	Active
PED193300-25	Child	PED	Children's Hospital	CHILDRENS HOSPITAL - Audrey Hepburn Care Center	1101 CALHOUN STREET	NEW ORLEANS	LA	Terminated
PED193300-26	Child	PED	Children's Hospital	CHILDRENS HOSPITAL INC - After Hours Clinic	3040 33RD STREET	METAIRIE	LA	Terminated
PED193300-27	Child	PED	Children's Hospital	CHMPC Napoleon Pediatric Clinic - CHNO CP NAPOLEON MET	3040 33RD STREET	METAIRIE	LA	Active
PED193300-28	Child	PED	Children's Hospital	CHMPC Napoleon Pediatric Clinic - CHNO CP NAPOLEON UPT	3700 SAINT CHARLES AVE	NEW ORLEANS	LA	Active
PED193300-29	Child	PED	Children's Hospital	Carousel Clinic	4224 HOUMA BLVD	METAIRIE	LA	Active
PED193300-30	Child	PED	Children's Hospital	CHMPC Ormond Pediatrics Group	141 ORMOND CENTER COURT	DESTREHAN	LA	Active
PED193300-31	Child	PED	Children's Hospital	CHMPC Lakeside Pediatric Clinic	4845 VETERANS BLVD	METAIRIE	LA	Active
PED193300-32	Child	PED	Children's Hospital	CHMPC Rainbow Clinic	451 RUE DE SANTE	LA PLACE	LA	Active
PED193300-33	Child	PED	Children's Hospital	CHMPC Slidell Clinic	3020 GAUSE BLVD EAST	SLIDELL	LA	Active
PED193300-34	Child	PED	Children's Hospital	Clinic - Specialty - Westbank	829 BARATARIA BLVD	MARRERO	LA	Active
PED193300-35	Child	PED	Children's Hospital	Clinic - Specialty - Northshore	5025 KEYSTONE BLVD-FIRST FLOOR	COVINGTON	LA	Active
PED193300-36	Child	PED	Children's Hospital	Emergency Department - MET ED	4545 VETERANS MEMORIAL BLVD	METAIRIE	LA	Active
PED193300-37	Child	PED	Children's Hospital	CHILDREN'S HOSP BEHAV HLTH HOSP - Psychiatry - Outpatient	210 STATE ST	NEW ORLEANS	LA	Approved
PED193300-38	Child	PED	Children's Hospital	CHILDREN'S HOSP BEHAV HLTH HOSP - Behavioral Health Services Community Wellness	210 STATE ST	NEW ORLEANS	LA	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Recertification		Children's Hospital 200 Henry Clay Ave New Orleans, LA 70118	9/6/2024 11:43 AM
Details	Last Recertification Date	Update	Recertification	8/25/2023 5:18:35 PM	9/6/2024 11:43:10 AM	9/6/2024 11:43 AM
Details	Entity Subname	Update	Recertification	CHILDREN'S HOSPITAL PEDIATRICS - BA - Westbank Specialty	Clinic - Specialty - Westbank	9/6/2024 11:43 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	000200302 (MS)		8/6/2024 4:24 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	00020302 (MS)		8/6/2024 4:24 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	100020317 (MS)		8/6/2024 4:24 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10025432 (TX)		8/6/2024 4:24 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	119660201 (TX)		8/6/2024 4:24 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1104819366 (MS)		8/6/2024 4:24 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1104819366 (TX)		8/6/2024 4:24 PM
Details	Last Recertification Date	Update	Recertification	9/15/2022 11:57:35 AM	8/25/2023 5:18:35 PM	8/25/2023 5:18 PM
Contacts	Authorizing Official	Update	Change Request	Nickens, John R President & CEO Children's Hospital 5048969452	Fragoso, Lucio A. President & CEO Children's Hospital 5048969452	1/13/2023 3:30 PM
Details	Last Recertification Date	Update	Recertification		9/15/2022 11:57:35 AM	9/15/2022 11:57 AM
Details	State	Update		Approved	Active	1/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Nickens, John R President & CEO Children's Hospital 5048969452	11/8/2021 7:18 AM
Details	340B ID	Update	New Registration		PED193300-34	11/8/2021 7:18 AM
Details	Entity Name	Update	New Registration	CHILDRENS HOSPITAL	Children's Hospital	11/8/2021 7:18 AM
Details	Entity Subname	Update	New Registration	CHILDREN'S HOSPITAL PEDIATRICS - BA	CHILDREN'S HOSPITAL PEDIATRICS - BA - Westbank Specialty	11/8/2021 7:18 AM
Dates	Participating Approval Date	Update	New Registration		11/8/2021 7:18:57 AM	11/8/2021 7:18 AM
Details	State	Update	New Registration	Pending	Approved	11/8/2021 7:18 AM
Dates	Signed By Date	Update	New Registration		10/25/2021 10:28:20 AM	11/8/2021 7:18 AM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	11/8/2021 7:18 AM
Addresses	Main Address	Insert	New Registration		829 BARATARIA BLVD MARRERO, LA 70072-1839	10/13/2021 6:08 PM
Addresses	Billing Address	Insert	New Registration		Children's Hospital 200 Henry Clay Ave New Orleans, LA 70118	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1734489	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000200302	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00020302	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100020317	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10025432	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		119660201	10/13/2021 6:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	10/13/2021 6:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104819366	10/13/2021 6:08 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	10/13/2021 6:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104819366	10/13/2021 6:08 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	10/13/2021 6:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104819366	10/13/2021 6:08 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	10/13/2021 6:08 PM
Contacts	Primary Contact	Insert	New Registration		Bosworth, Lindy C Director of Pharmacy Children's Hospital 5048946764	10/13/2021 6:08 PM
Contacts	Authorizing Official	Insert	New Registration		Nickens, John R President & CEO Children's Hospital 5048969452	10/13/2021 6:08 PM
Details	Assistance Received From Date	Insert	New Registration			10/13/2021 6:08 PM
Details	Assistance Received To Date	Insert	New Registration			10/13/2021 6:08 PM
Details	Last Recertification Date	Insert	New Registration			10/13/2021 6:08 PM
Details	Grant Number	Insert	New Registration			10/13/2021 6:08 PM
Details	340B ID	Insert	New Registration			10/13/2021 6:08 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/13/2021 6:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/13/2021 6:08 PM
Details	Medicare Provider Number	Insert	New Registration		193300	10/13/2021 6:08 PM
Details	Entity Name	Insert	New Registration		CHILDRENS HOSPITAL	10/13/2021 6:08 PM
Details	NOFO Number	Insert	New Registration			10/13/2021 6:08 PM
Details	Program Code	Insert	New Registration		PED	10/13/2021 6:08 PM
Details	Entity Subname	Insert	New Registration		CHILDREN'S HOSPITAL PEDIATRICS - BA	10/13/2021 6:08 PM
Dates	Participating Approval Date	Insert	New Registration			10/13/2021 6:08 PM
Details	State	Insert	New Registration		Pending	10/13/2021 6:08 PM
Dates	Registration Date	Insert	New Registration		10/13/2021 6:08:20 PM	10/13/2021 6:08 PM
Dates	Signed By Date	Insert	New Registration			10/13/2021 6:08 PM
Dates	Start Date	Insert	New Registration			10/13/2021 6:08 PM
Terminations	Termination Comments	Insert	New Registration			10/13/2021 6:08 PM
Terminations	Termination Date	Insert	New Registration			10/13/2021 6:08 PM
Terminations	Termination Effective Date	Insert	New Registration			10/13/2021 6:08 PM
Terminations	Termination Reason	Insert	New Registration			10/13/2021 6:08 PM