Covered Entity Details

DSH450571J SHANNON MEDICAL CENTER (Active) - information as of 5/13/2025 1:48:29 AM

Main Details

Name

SHANNON MEDICAL CENTER

Subdivision Name

SHANNON SURGERY CENTER SOUTH - SURGERY CENTER SOUTH - EXECUTIVE 7214

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH450571J

Medicare Provider Number

450571

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/14/2022

Participating Start Date

7/1/2022

Participating Approval Date

5/6/2022

Last Recertification Date

8/30/2024

Contacts

Authorizing Official

Shannon Medical Center
Joseph Wooldridge, Chief Financial Officer
(325) 657-5303

Primary Contact

Shannon Medical Center
Stephanie McCann, Pharmacy Director
(325) 747-5287

Addresses

Street Address

3605 EXECUTIVE DR
SAN ANGELO, TX 76904-6884

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	137226005	1992707228

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
DSH450571A	Child	DSH	SHANNON MEDICAL CENTER	SHANNON RIVER CREST HOSPITAL - OUTPT PYSCH	1636 HUNTERS GLEN RD	SAN ANGELO	TX	Approved
DSH450571B	Child	DSH	SHANNON MEDICAL CENTER	SHANNON SURGERY CENTER	4482 SUNSET DR.	SAN ANGELO	TX	Terminated
DSH450571C	Child	DSH	SHANNON MEDICAL CENTER	SHANNON ADULT OP CHEMO CLINIC	102 N. MAGDALEN	SAN ANGELO	TX	Terminated
DSH450571D	Child	DSH	SHANNON MEDICAL CENTER	Shannon Dialysis Center	2018 Pulliam	San Angelo	TX	Terminated
DSH450571E	Child	DSH	SHANNON MEDICAL CENTER	Shannon Infusion Clinic	2018 Pulliam	San Angelo	TX	Terminated
DSH450571F	Child	DSH	SHANNON MEDICAL CENTER	Woundcare & Hyperbaric Clinic	2018 Pulliam	San Angelo	TX	Terminated
DSH450571H	Child	DSH	SHANNON MEDICAL CENTER	Dialysis Services-Brady	2008 NINE RD	BRADY	TX	Terminated
DSH450571J	Child	DSH	SHANNON MEDICAL CENTER	SHANNON SURGERY CENTER SOUTH - SURGERY CENTER SOUTH - EXECUTIVE 7214	3605 EXECUTIVE DR	SAN ANGELO	TX	Active
DSH450571K	Child	DSH	SHANNON MEDICAL CENTER	SHANNON RADIOLOGY OUTPATIENT DEPT - O/P RADIOLOGY CT SCAN 7045	120 E BEAUREGARD AVE	SAN ANGELO	TX	Terminated
DSH450571L	Child	DSH	SHANNON MEDICAL CENTER	SHANNON MEDICAL CENTER-ST JOHN CAMP - OP HYPERBARIC 7111	2018 PULLIAM ST	SAN ANGELO	TX	Terminated
DSH450571M	Child	DSH	SHANNON MEDICAL CENTER	SHANNON SURGERY CENTER - SURGERY CENTER - SUNSET 6229	4482 SUNSET DR	SAN ANGELO	TX	Active
DSH450571N	Child	DSH	SHANNON MEDICAL CENTER	SHANNON NEURO REHABILITATION - OP NEURO REHAB 7096	3501 EXECUTIVE DR	SAN ANGELO	TX	Terminated
DSH450571P	Child	DSH	SHANNON MEDICAL CENTER	SHANNON IMAGING CENTER - OP MRI 7054	3301 S BRYANT BLVD	SAN ANGELO	TX	Terminated
DSH450571Q	Child	DSH	SHANNON MEDICAL CENTER	SHANNON MEDICAL CENTER SOUTH - OP HYPERBARIC SOUTH 7308	3501 KNICKERBOCKER RD	SAN ANGELO	TX	Terminated
DSH450571R	Child	DSH	SHANNON MEDICAL CENTER	SHANNON MEDICAL CENTER INFUSION - OP INFUSION CLINIC 7068	3501 KNICKERBOCKER RD	SAN ANGELO	TX	Active
DSH450571S	Child	DSH	SHANNON MEDICAL CENTER	SHANNON MEDICAL CENTER SOUTH - OP WOUNDCARE SOUTH 7110	3501 KNICKERBOCKER RD	SAN ANGELO	TX	Active
DSH450571T	Child	DSH	SHANNON MEDICAL CENTER	SHANNON ONCOLOGY CENTER - OP ONCOLOGY 7517	131 E Beauregard Ave	SAN ANGELO	TX	Active
DSH450571U	Child	DSH	SHANNON MEDICAL CENTER	SHANNON MEDICAL CENTER-ST JOHN CAMP - OP WOUNDCARE 7110	2018 PULLIAM ST	SAN ANGELO	TX	ToBeTerminated
DSH450571V	Child	DSH	SHANNON MEDICAL CENTER	SHANNON NUCLEAR MED MAGDALEN 7047 - Nuclear Medicine	102 N MAGDALEN	SAN ANGELO	TX	Active
DSH450571W	Child	DSH	SHANNON MEDICAL CENTER	SHANNON MEDICAL CENTER SOUTH - EMERGENCY DEPARTMENT 6391 - EMERGENCY ROOM	3501 KNICKERBOCKER RD	SAN ANGELO	TX	Active
DSH450571X	Child	DSH	SHANNON MEDICAL CENTER	SHANNON MEDICATION THERAPY MANAGEMENT 7072 - Medication Therapy Management	122 South Oakes STE 101	San Angelo	TX	Active
DSH450571Y	Child	DSH	SHANNON MEDICAL CENTER	SHANNON PET SCAN CANCER CENTER 7055 - RADIOLOGY	131 E Beauregard Ave Ste 203	San Angelo	TX	Active
DSH450571Z	Child	DSH	SHANNON MEDICAL CENTER	SHANNON CANCER CENTER-MEDICAL ONC - Oncology	131 E BEAUREGARD AVE	SAN ANGELO	TX	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	PC Change Request	Hughes, Abby 340B Coordinator Shannon Medical Center 3256575255	McCann, Stephanie Pharmacy Director Shannon Medical Center 3257475287	4/23/2025 3:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/30/2024 4:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		137226005	8/30/2024 4:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	8/30/2024 4:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992707228	8/30/2024 4:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/30/2024 4:22 PM
Details	Last Recertification Date	Update	Recertification	8/23/2023 4:09:43 PM	8/30/2024 4:22:32 PM	8/30/2024 4:22 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 10:44:32 AM	8/23/2023 4:09:43 PM	8/23/2023 4:09 PM
Contacts	Primary Contact	Update	Profile Change Request	Hughes, Abby 340B Coordinator Shannon Medical Center 3256575189	Hughes, Abby 340B Coordinator Shannon Medical Center 3256575255	11/23/2022 2:57 PM
Details	Last Recertification Date	Update	Recertification		9/6/2022 10:44:32 AM	9/6/2022 10:44 AM
Contacts	Primary Contact	Update	Group Change Request	Lubke, Steve Director of Pharmacy Services Shannon Medical Center 3256575189	Hughes, Abby 340B Coordinator Shannon Medical Center 3256575189	7/11/2022 7:05 AM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Wooldridge, Joseph Chief Financial Officer Shannon Medical Center 3256575303	5/6/2022 9:30 AM
Details	340B ID	Update	New Registration		DSH450571J	5/6/2022 9:30 AM
Details	Entity Subname	Update	New Registration	SHANNON SURGERY CENTER SOUTH	SHANNON SURGERY CENTER SOUTH - SURGERY CENTER SOUTH - EXECUTIVE 7214	5/6/2022 9:30 AM
Dates	Participating Approval Date	Update	New Registration		5/6/2022 9:30:22 AM	5/6/2022 9:30 AM
Details	State	Update	New Registration	Pending	Approved	5/6/2022 9:30 AM
Dates	Signed By Date	Update	New Registration		5/1/2022 7:16:43 AM	5/6/2022 9:30 AM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	5/6/2022 9:30 AM
Addresses	Main Address	Insert	New Registration		3605 EXECUTIVE DR SAN ANGELO, TX 76904-6884	4/14/2022 5:54 PM
Contacts	Primary Contact	Insert	New Registration		Lubke, Steve Director of Pharmacy Services Shannon Medical Center 3256575189	4/14/2022 5:54 PM
Contacts	Authorizing Official	Insert	New Registration		Wooldridge, Joseph Chief Financial Officer Shannon Medical Center 3256575303	4/14/2022 5:54 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2022 5:54 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2022 5:54 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2022 5:54 PM
Details	Grant Number	Insert	New Registration			4/14/2022 5:54 PM
Details	340B ID	Insert	New Registration			4/14/2022 5:54 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2022 5:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2022 5:54 PM
Details	Medicare Provider Number	Insert	New Registration		450571	4/14/2022 5:54 PM
Details	Entity Name	Insert	New Registration		SHANNON MEDICAL CENTER	4/14/2022 5:54 PM
Details	NOFO Number	Insert	New Registration			4/14/2022 5:54 PM
Details	Program Code	Insert	New Registration		DSH	4/14/2022 5:54 PM
Details	Entity Subname	Insert	New Registration		SHANNON SURGERY CENTER SOUTH	4/14/2022 5:54 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2022 5:54 PM
Details	State	Insert	New Registration		Pending	4/14/2022 5:54 PM
Dates	Registration Date	Insert	New Registration		4/14/2022 5:54:28 PM	4/14/2022 5:54 PM
Dates	Signed By Date	Insert	New Registration			4/14/2022 5:54 PM
Dates	Start Date	Insert	New Registration			4/14/2022 5:54 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2022 5:54 PM
Terminations	Termination Date	Insert	New Registration			4/14/2022 5:54 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2022 5:54 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2022 5:54 PM