Covered Entity Details

CH062776D Health Center Of Southeast Texas (Active) - information as of 4/29/2025 1:40:24 AM

Main Details

Name

Health Center Of Southeast Texas

Subdivision Name

Health Center of Southeast Texas - Terrenos

Type

HRSA-Funded Health Center

Site ID

BPS-H80-034349

340B ID

CH062776D

Grant Number

H80CS08770

Additional Details

Current Program Status

Active

Registration Date

3/31/2022

Participating Start Date

4/4/2022

Participating Approval Date

4/4/2022

Last Recertification Date

2/20/2025

Contacts

Authorizing Official

Health Center of Southeast Texas
Steven Racciato, CEO
(281) 592-2224 Ext: 218

Primary Contact

Health Center of Southeast Texas
Andee Kesner, Pharmacy Director
(281) 592-2224 Ext: 257

Addresses

Street Address

871 CR 3549
Cleveland, TX 77327

Billing Address

Health Center of Southeast Texas
307 N. William Barnett Ave
CLEVELAND, TX 77327

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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	179566803	1265197867,1225059686

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.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH0627760	Active	BPS-H80-010405	HEALTH CENTER OF SOUTHEAST TEXAS	Health Center of Southeast Texas	307 N. William Barnett Ave.	Cleveland	TX
CH062776A	Active	BPS-H80-013987	HEALTH CENTER OF SOUTHEAST TEXAS	Health Center of Southeast Texas - Shepherd	11 Woodland Park Dr	Shepherd	TX
CH062776B	Active	BPS-H80-038082	HEALTH CENTER OF SOUTHEAST TEXAS	Health Center of Southeast Texas - Liberty	1400 N Travis St	LIBERTY	TX
CH062776C	Active	BPS-H80-015684	Health Center Of Southeast Texas	Health Center of Southeast Texas - Livingston	204 W Park	Livingston	TX
CH062776D	Active	BPS-H80-034349	Health Center Of Southeast Texas	Health Center of Southeast Texas - Terrenos	871 CR 3549	Cleveland	TX
CH062776E	Active	BPS-H80-032862	Health Center Of Southeast Texas	Health Center of Southeast Texas - Dayton	2206 N Cleveland St	Dayton	TX

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH0627760	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2022	09/01/2022
CH0627760	WAL-MART PHARMACY 10-0249	831 HWY. 59 SOUTH		CLEVELAND	TX	77327	10/01/2020	09/01/2022
CH0627760	WAL-MART PHARMACY 10-0275	1620 W. CHURCH		LIVINGSTON	TX	77351	04/01/2022	09/01/2022
CH0627760	WAL-MART PHARMACY 10-1186	2121 US BYPASS 146		LIBERTY	TX	77575	04/01/2022	09/01/2022
CH0627760	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2022	09/01/2022
CH0627760	WALGREEN CO.	DBA: WALGREENS #11814	101 S. WASHINGTON AVE.	CLEVELAND	TX	77327-4414	09/09/2011
CH0627760	WALGREEN CO.	DBA: WALGREENS # 06932	24917 FM 1314 RD	PORTER	TX	77365-4982	09/09/2011
CH0627760	WALGREEN CO.	DBA: WALGREENS # 07878	209 W. HIGHWAY 90	DAYTON	TX	77535	09/09/2011
CH0627760	WALGREEN CO.	DBA: WALGREENS # 01518	14402 FM 2100 RD	CROSBY	TX	77532	01/01/2013
CH0627760	WALGREEN CO.	DBA: WALGREENS # 03025	7440 FM 1960 E.	HUMBLE	TX	77346	01/01/2013
CH0627760	WALGREEN CO.	DBA: WALGREENS #12165	3901 E. DAVIS ST.	CONROE	TX	77301	01/01/2013
CH0627760	WALGREEN CO.	DBA WALGREENS #15542	20824 FM 1485 RD	NEW CANEY	TX	77357	04/01/2017
CH062776C	WALGREEN CO.	WALGREENS #21238	1501 W CHURCH ST, STE 500	LIVINGSTON	TX	77351-3075	04/01/2020	06/30/2023
CH0627760	WALGREEN CO.	WALGREENS #21238	1501 W CHURCH ST, STE 500	LIVINGSTON	TX	77351-3075	07/01/2023
CH0627760	Walgreens #21373	Walgreens Central Fill #21373	4100 Dale Earnhardt Way STE 200	Northlake	TX	76262	01/01/2022

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/6/2024 4:42:34 PM	2/20/2025 10:32:17 AM	2/20/2025 10:32 AM
Details	Last Recertification Date	Update	Recertification	1/31/2023 10:40:20 AM	2/6/2024 4:42:34 PM	2/6/2024 4:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225059686	10/25/2023 7:31 AM
Medicaid Billing	NPI: State	Insert	Change Request		TX	10/25/2023 7:31 AM
Details	Last Recertification Date	Update	Recertification		1/31/2023 10:40:20 AM	1/31/2023 10:40 AM
Contacts	Authorizing Official	Update	New Registration	Racciato, Steven CEO Health Center of Southeast Texas 2815922224	Racciato, Steven CEO Health Center of Southeast Texas 2815922224-218	5/3/2022 12:01 PM
Contacts	Signed By	Update	New Registration	Racciato, Steven CEO Health Center of Southeast Texas 2815922224	Racciato, Steven CEO Health Center of Southeast Texas 2815922224-218	5/3/2022 12:01 PM
Details	State	Update	OPA Edit	Approved	Active	4/4/2022 8:51 AM
Dates	Start Date	Update	OPA Edit	7/1/2022 12:00:00 AM	4/4/2022 12:00:00 AM	4/4/2022 8:51 AM
Contacts	Signed By	Insert	New Registration		Racciato, Steven CEO Health Center of Southeast Texas 2815922224	4/4/2022 6:47 AM
Details	340B ID	Update	New Registration		CH062776D	4/4/2022 6:47 AM
Dates	Participating Approval Date	Update	New Registration		4/4/2022 6:47:55 AM	4/4/2022 6:47 AM
Details	State	Update	New Registration	Pending	Approved	4/4/2022 6:47 AM
Dates	Signed By Date	Update	New Registration		3/31/2022 10:17:22 AM	4/4/2022 6:47 AM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	4/4/2022 6:47 AM
Addresses	Main Address	Insert	New Registration		871 CR 3549 Cleveland, TX 77327	3/31/2022 10:17 AM
Addresses	Billing Address	Insert	New Registration		Health Center of Southeast Texas 307 N. William Barnett Ave CLEVELAND, TX 77327	3/31/2022 10:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	3/31/2022 10:17 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		179566803	3/31/2022 10:17 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	3/31/2022 10:17 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1265197867	3/31/2022 10:17 AM
Medicaid Billing	NPI: State	Insert	New Registration		TX	3/31/2022 10:17 AM
Contacts	Authorizing Official	Insert	New Registration		Racciato, Steven CEO Health Center of Southeast Texas 2815922224	3/31/2022 10:17 AM
Contacts	Primary Contact	Insert	New Registration		Kesner, Andee Pharmacy Director Health Center of Southeast Texas 2815922224-257	3/31/2022 10:17 AM
Details	Assistance Received From Date	Insert	New Registration			3/31/2022 10:17 AM
Details	Assistance Received To Date	Insert	New Registration			3/31/2022 10:17 AM
Details	Last Recertification Date	Insert	New Registration			3/31/2022 10:17 AM
Details	Grant Number	Insert	New Registration		H80CS08770	3/31/2022 10:17 AM
Details	340B ID	Insert	New Registration			3/31/2022 10:17 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			3/31/2022 10:17 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			3/31/2022 10:17 AM
Details	Medicare Provider Number	Insert	New Registration			3/31/2022 10:17 AM
Details	Entity Name	Insert	New Registration		Health Center Of Southeast Texas	3/31/2022 10:17 AM
Details	NOFO Number	Insert	New Registration			3/31/2022 10:17 AM
Details	Program Code	Insert	New Registration		CH	3/31/2022 10:17 AM
Details	Entity Subname	Insert	New Registration		Health Center of Southeast Texas - Terrenos	3/31/2022 10:17 AM
Dates	Participating Approval Date	Insert	New Registration			3/31/2022 10:17 AM
Details	State	Insert	New Registration		Pending	3/31/2022 10:17 AM
Dates	Registration Date	Insert	New Registration		3/31/2022 10:17:18 AM	3/31/2022 10:17 AM
Dates	Signed By Date	Insert	New Registration			3/31/2022 10:17 AM
Dates	Start Date	Insert	New Registration			3/31/2022 10:17 AM
Terminations	Termination Comments	Insert	New Registration			3/31/2022 10:17 AM
Terminations	Termination Date	Insert	New Registration			3/31/2022 10:17 AM
Terminations	Termination Effective Date	Insert	New Registration			3/31/2022 10:17 AM
Terminations	Termination Reason	Insert	New Registration			3/31/2022 10:17 AM

340B Drug Pricing Program Database