Covered Entity Details

DSH450587A HENDRICK MEDICAL CENTER BROWNWOOD (Terminated) - information as of 4/30/2025 10:55:00 PM

Main Details

Name

HENDRICK MEDICAL CENTER BROWNWOOD

Subdivision Name

Hendrick Imaging and Breast Center Brownwood - RADIOLOGY - REMOTE SITE 3 - RADIOLOGY - REMOTE SITE 3 - 35460

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH450587A

Medicare Provider Number

450587

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/7/2022

Participating Start Date

10/1/2022

Participating Approval Date

8/24/2022

Last Recertification Date

8/20/2024

Termination Date
Termination Reason

1/1/2025
Change of covered entity type

Contacts

Authorizing Official

Hendrick Medical Center Brownood
Erich Wallschlaeger, Chief Financial Officer
(325) 649-3305

Primary Contact

Hendrick Medical Center
Robert Joseph Wray, pharmacist
(325) 670-6405

Addresses

Street Address

105 Streckert Dr.
Brownwood, TX 76801

Billing Address

Hendrick Medical Center Brownwood
1501 Burnett Rd.
Brownwood, TX 76801

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	420957901	1184233785

Shipping Addresses

Shipping Address 1

Hendrick Medical Center Brownwood
1501 Burnett Rd.
Brownwood, TX 76801

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
DSH450587A	Child	DSH	HENDRICK MEDICAL CENTER BROWNWOOD	Hendrick Imaging and Breast Center Brownwood - RADIOLOGY - REMOTE SITE 3 - RADIOLOGY - REMOTE SITE 3 - 35460	105 Streckert Dr.	Brownwood	TX	Terminated
DSH450587B	Child	DSH	HENDRICK MEDICAL CENTER BROWNWOOD	Hendrick Wound Care Center Brownwood - Hendrick Wound Care Center Brownwood - 34225	123 S Park Dr.	Brownwood	TX	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	10/30/2024 10:14 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	10/30/2024 10:14 AM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	10/30/2024 10:14 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	10/30/2024 10:14 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	10/30/2024 10:14 AM
Details	Last Recertification Date	Update	Recertification	9/1/2023 2:29:57 PM	8/20/2024 10:06:01 AM	8/20/2024 10:06 AM
Details	Last Recertification Date	Update	Recertification		9/1/2023 2:29:57 PM	9/1/2023 2:29 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	20930601 (TX)		3/25/2023 12:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/25/2023 12:16 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		420957901	3/25/2023 12:16 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	3/25/2023 12:16 PM
Details	State	Update		Approved	Active	10/1/2022 12:01 AM
Details	Entity Name	Update	Change Request	BROWNWOOD REGIONAL MEDICAL CENTER	HENDRICK MEDICAL CENTER BROWNWOOD	9/12/2022 1:00 PM
Contacts	Signed By	Insert	New Registration		Wallschlaeger, Erich Chief Financial Officer Hendrick Medical Center Brownood 3256493305	8/24/2022 11:37 AM
Details	340B ID	Update	New Registration		DSH450587A	8/24/2022 11:37 AM
Details	Entity Subname	Update	New Registration	Hendrick Imaging and Breast Center Brownwood - RADIOLOGY - REMOTE SITE 3	Hendrick Imaging and Breast Center Brownwood - RADIOLOGY - REMOTE SITE 3 - RADIOLOGY - REMOTE SITE 3 - 35460	8/24/2022 11:37 AM
Dates	Participating Approval Date	Update	New Registration		8/24/2022 11:37:01 AM	8/24/2022 11:37 AM
Details	State	Update	New Registration	Pending	Approved	8/24/2022 11:37 AM
Dates	Signed By Date	Update	New Registration		7/13/2022 10:25:53 AM	8/24/2022 11:37 AM
Dates	Start Date	Update	New Registration		10/1/2022 12:00:00 AM	8/24/2022 11:37 AM
Addresses	Main Address	Insert	New Registration		105 Streckert Dr. Brownwood, TX 76801	7/7/2022 11:30 AM
Addresses	Billing Address	Insert	New Registration		Hendrick Medical Center Brownwood 1501 Burnett Rd. Brownwood, TX 76801	7/7/2022 11:30 AM
Addresses	Shipping Address	Insert	New Registration		Hendrick Medical Center Brownwood 1501 Burnett Rd. Brownwood, TX 76801	7/7/2022 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2022 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		20930601	7/7/2022 11:30 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	7/7/2022 11:30 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1184233785	7/7/2022 11:30 AM
Medicaid Billing	NPI: State	Insert	New Registration		TX	7/7/2022 11:30 AM
Contacts	Primary Contact	Insert	New Registration		Wray, Robert Joseph pharmacist Hendrick Medical Center 3256706405	7/7/2022 11:30 AM
Contacts	Authorizing Official	Insert	New Registration		Wallschlaeger, Erich Chief Financial Officer Hendrick Medical Center Brownood 3256493305	7/7/2022 11:30 AM
Details	Assistance Received From Date	Insert	New Registration			7/7/2022 11:30 AM
Details	Assistance Received To Date	Insert	New Registration			7/7/2022 11:30 AM
Details	Last Recertification Date	Insert	New Registration			7/7/2022 11:30 AM
Details	Grant Number	Insert	New Registration			7/7/2022 11:30 AM
Details	340B ID	Insert	New Registration			7/7/2022 11:30 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/7/2022 11:30 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/7/2022 11:30 AM
Details	Medicare Provider Number	Insert	New Registration		450587	7/7/2022 11:30 AM
Details	Entity Name	Insert	New Registration		BROWNWOOD REGIONAL MEDICAL CENTER	7/7/2022 11:30 AM
Details	NOFO Number	Insert	New Registration			7/7/2022 11:30 AM
Details	Program Code	Insert	New Registration		DSH	7/7/2022 11:30 AM
Details	Entity Subname	Insert	New Registration		Hendrick Imaging and Breast Center Brownwood - RADIOLOGY - REMOTE SITE 3	7/7/2022 11:30 AM
Dates	Participating Approval Date	Insert	New Registration			7/7/2022 11:30 AM
Details	State	Insert	New Registration		Pending	7/7/2022 11:30 AM
Dates	Registration Date	Insert	New Registration		7/7/2022 11:30:08 AM	7/7/2022 11:30 AM
Dates	Signed By Date	Insert	New Registration			7/7/2022 11:30 AM
Dates	Start Date	Insert	New Registration			7/7/2022 11:30 AM
Terminations	Termination Comments	Insert	New Registration			7/7/2022 11:30 AM
Terminations	Termination Date	Insert	New Registration			7/7/2022 11:30 AM
Terminations	Termination Effective Date	Insert	New Registration			7/7/2022 11:30 AM
Terminations	Termination Reason	Insert	New Registration			7/7/2022 11:30 AM