Covered Entity Details

DSH450032CF GOOD SHEPHERD MEDICAL CENTER (Active) - information as of 4/25/2025 8:31:10 PM

Main Details

Name

GOOD SHEPHERD MEDICAL CENTER

Subdivision Name

CHRISTUS TRINITY CLINIC - ENT

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450032CF

Medicare Provider Number

450032

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/3/2023

Participating Start Date

4/1/2023

Participating Approval Date

1/9/2023

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Good Shepherd Medical Center
Michael Cheek, CFO
(903) 315-1814

Primary Contact

CHRISTUS Good Shepherd Medical Center
Jamie Lee Georgiev, Senior Pharmacy Buyer
(903) 315-3127

Addresses

Street Address

705 E MARSHALL AVE
STE 4003
Longview, TX 75601

Billing Address

GOOD SHEPHERD MEDICAL CENTER
700 E. MARSHALL AVENUE
Longview, TX 75601

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	1126674	1124092036

Shipping Addresses

Shipping Address 1

GOOD SHEPHERD MEDICAL CENTER
700 E. MARSHALL AVENUE
Longview, TX 75601

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
DSH450032A	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Marshall Pediatric Clinic	707 S. Grove	Marshall	TX	Terminated
DSH450032AA	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Outpatient Imaging (323 E Hawkins location)	323 East Hawkins Parkway	Longview	TX	Active
DSH450032AB	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Longview Institute for Healthy Living - Wellness Clinic-- Speech Therapy	3133 Good Shepherd Way	Longview	TX	Active
DSH450032AC	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	S200 Pediatric Outpt Longview - Pediatric	700 E Marshall Ave	Longview	TX	Terminated
DSH450032AD	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Urology LGV	703 E Marshall	Longview	TX	Active
DSH450032AE	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	CHRISTUS Trinity Clinic CV Surg LV - Clinic	700 E Marshall	Longview	TX	Terminated
DSH450032AF	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Ortho LGV - Clinic	701 E Marshall	Longview	TX	Terminated
DSH450032AG	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Surgery LGV	705 E Marshall	Longview	TX	Active
DSH450032AH	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Gastro MSH	815 S Washington Ave	Marshall	TX	Active
DSH450032AJ	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CTC Family Medicine NorthPark	323 E. Hawkins Parkway	Longview	TX	Active
DSH450032AK	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Surgery MSH	815 S Washington Ave	Marshall	TX	Active
DSH450032AL	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Ortho MSH	815 S Washington Ave	Marshall	TX	Active
DSH450032AM	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Gastro LG	701 E Marshall	Longview	TX	Active
DSH450032AN	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Int Med LGV	703 E Marshall	Longview	TX	Active
DSH450032AP	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Podiatry LGV - Clinic	705 E. Marshall	Longview	TX	Terminated
DSH450032AQ	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Residency LGV	701 E Marshall	Longview	TX	Active
DSH450032AR	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Cardio LGV - Clinic	703 E Marshall	Longview	TX	Terminated
DSH450032AS	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Int Med MSH	815 S Washington Ave	Marshall	TX	Active
DSH450032AT	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	GOOD SHEPHERD MEDICAL CTR - Occup Ther - Occupational Therapy	3133 Good Shepherd Way	Longview	TX	Terminated
DSH450032AU	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	GOOD SHEPHERD MEDICAL CTR - Speech - Speech Therapy	3133 Good Shepherd Way	Longview	TX	Terminated
DSH450032AV	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Specialty Clinic	815 S Washington Ave	Marshall	TX	Active
DSH450032AW	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	GOOD SHEPHERD MEDICAL CTR - Cardiac Rehab	3133 Good Shepherd Way	Longview	TX	Terminated
DSH450032AX	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Good Shepherd Breast Center - Clinic	705 E. Marshall	Longview	TX	Active
DSH450032AY	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Good Shepherd ASC - Surgery	700 E Marshall	Longview	TX	Terminated
DSH450032AZ	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	GOOD SHEPHERD MEDICAL CTR - North Park - Emergency Services	323 E Hawkins Parkway	Longview	TX	Active
DSH450032B	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	East Texas Pediatrics	618 S. Grove	Marshall	TX	Terminated
DSH450032BA	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Outpatient Rehab - Physical Therapy	612 S. Grove	Marshall	TX	Active
DSH450032BB	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	GOOD SHEPHERD MEDICAL CTR - Physical Therapy	2220 H G Mosley Parkway	Longview	TX	Terminated
DSH450032BC	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Outpatient Rehab - Speech Therapy	612 S. Grove	Marshall	TX	Active
DSH450032BD	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Infusion Clinic - Infusion	323 E Hawkins Pkwy	Longview	TX	Terminated
DSH450032BE	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	GOOD SHEPHERD MEDICAL CTR - PT Sports Med - Physical Therapy	3133 Good Shepherd Way	Longview	TX	Terminated
DSH450032BF	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Outpatient Rehab - Occupational Therapy	612 S. Grove	Marshall	TX	Active
DSH450032BG	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Hemodialysis - Hemodialysis	811 S. Washington	Marshall	TX	Active
DSH450032BH	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall CT - CT	811 S. Washington	Marshall	TX	Active
DSH450032BJ	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Radiology	811 S. Washington	Marshall	TX	Active
DSH450032BK	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - PAIN/NEURO LGV	703 E MARSHALL AVE	Longview	TX	Active
DSH450032BL	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	WOUND HEALING CENTER - Wound Care	618 S GROVE ST	MARSHALL	TX	Active
DSH450032BM	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Respiratory Therapy - Respiratory Therapy	811 S. Washington	Marshall	TX	Active
DSH450032BN	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Interventional Radiology - Interventional Radiology	811 S Washington Ave	Marshall	TX	Active
DSH450032BP	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - INTERNAL MED MSH - INTERNAL MED MSH	811 S WASHINGTON AVE	Marshall	TX	Terminated
DSH450032BQ	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	GOOD SHEPHERD ASC	703 E MARSHALL AVE	Longview	TX	Active
DSH450032BR	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Surgery - Surgery	811 S Washington Ave	Marshall	TX	Active
DSH450032BS	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Laboratory - Laboratory	811 S Washington Ave	Marshall	TX	Active
DSH450032BT	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall MRI - MRI	811 S Washington Ave	Marshall	TX	Active
DSH450032BU	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Cardiology Non invasive - Cardiology Non invasive	811 S Washington Ave	Marshall	TX	Active
DSH450032BV	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Longview Institute for Healthy Living - Wellness Clinic-- Physical Therapy - E. Hawkins Location	3133 Good Shepherd Way	Longview	TX	Active
DSH450032BW	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Cardiac Rehab - Cardiac Rehab	811 S Washington Ave	Marshall	TX	Active
DSH450032BX	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS GOOD SHEPHERD CENTER FOR SLEEP DISORDERS	705 E MARSHALL AVE	Longview	TX	Active
DSH450032BY	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Longview Institute for Healthy Living - Wellness Clinic-- Occupational Therapy	3133 Good Shepherd Way	Longview	TX	Active
DSH450032BZ	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Marshall Emergency Room - Emergency Room	811 S Washington Ave	Marshall	TX	Active
DSH450032C	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Good Shepherd Family Health Center	805 S. Lindsey St.	Marshall	TX	Terminated
DSH450032CA	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - ORTHOPEDIC SURGERY - ORTHOPEDIC SURGERY	3133 Good Shepherd Way	Longview	TX	Active
DSH450032CB	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - CV SURGERY LGV - CV SURGERY	701 E MARSHALL AVE	LONGVIEW	TX	Terminated
DSH450032CC	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - UROLOGY MSH	815 S. Washington Ave.	Marshall	TX	Active
DSH450032CD	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Orthopedics & Sports Medicine Institute	3133 Good Shepherd Way	Longview	TX	Active
DSH450032CE	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS GOOD SHEPHERD HEART & VASCULAR INSTITUTE - Cardiac Rehab	707 E. MARSHALL AVENUE	Longview	TX	Active
DSH450032CF	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - ENT	705 E MARSHALL AVE	Longview	TX	Active
DSH450032CG	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - MARSHALL PAIN CLINIC - Pain Clinic	815 S WASHINGTON AVE	Marshall	TX	Terminated
DSH450032CH	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS GOOD SHEPHERD HEART & VASCULAR INSTITUTE - Imaging - Nuclear Medicine	707 E MARSHALL AVE	Longview	TX	Active
DSH450032CJ	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS GOOD SHEPHERD HEART & VASCULAR INSTITUTE - Specialty Cardio	707 E MARSHALL AVE	Longview	TX	Active
DSH450032CK	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS GOOD SHEPHERD HEART & VASCULAR INSTITUTE - Electro Cardiology	707 E. MARSHALL AVENUE	Longview	TX	Active
DSH450032CL	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - Surgey - Plastic Surgery	705 E. MARSHALL AVE.	LONGVIEW	TX	Active
DSH450032CM	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - PULMONARY & CARDIOVASCULAR SURGERY	705 E. MARSHALL AVE	LONGVIEW	TX	Active
DSH450032CN	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS ORTHOPEDIC & SPORTS MEDICI - Podiatry	3133 GOOD SHEPHERD WAY	LONGVIEW	TX	Active
DSH450032CP	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS Trinity Clinic - Multi-Specialty	703 E Marshall Ave.	Longview	TX	Active
DSH450032CQ	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Kilgore - Clinic Services	1718 S. Henderson Blvd	Kilgore	TX	Terminated
DSH450032CR	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC FAMILY MEDI - Family Medicine	1614 S HENDERSON BLVD	KILGORE	TX	Active
DSH450032CS	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - LONGVIEW - INFECTIOUS DISEASE	703 E. Marshall	Longview	TX	Active
DSH450032CT	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	NORTHPARK - Surg Anesthesiology	323 E. Hawkins	Longview	TX	Active
DSH450032CU	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - MARSHALL OUTREACH - ORTHOPEDICS AND PODIATRY	815 S WASHINGTON AVE	MARSHALL	TX	Active
DSH450032CV	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	NORTHPARK - General Surgery	323 E. Hawkins	Longview	TX	Active
DSH450032CW	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CTC - PULMONOLOGY	815 S. WASHINGTON AVE.	MARSHALL	TX	Active
DSH450032CX	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	NORTHPARK - Post Surgical PACU	323 E. Hawkins	Longview	TX	Active
DSH450032CY	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	NORTHPARK - Radiology Outpatient	323 E. Hawkins	Longview	TX	Active
DSH450032D	Child	DSH	GOOD SHEPHERD MEDICAL CTR - MARSHALL	First in Pediatrics RHC	304 University Ave.	Marshall	TX	Terminated
DSH450032E	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	MRI - Longview - MRI	700 E Marshall Ave	Longview	TX	Terminated
DSH450032F	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Nuclear Medicine - Longview - Radiology - Diagnostic	700 E Marshall Ave	Longview	TX	Terminated
DSH450032G	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Pulmonary Services - Longview - Respiratory Therapy	700 E Marshall Ave	Longview	TX	Terminated
DSH450032H	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Surgery Dept - Longview - Operating Room	700 E Marshall Ave	Longview	TX	Terminated
DSH450032J	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Diagnostic Radiology - Longvew - Radiology - Diagnostic	700 E Marshall Ave	Longview	TX	Terminated
DSH450032K	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Kilgore ED - Emergency	1612 South Henderson Blvd	Kilgore	TX	Active
DSH450032L	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Longview Northpark Emergency Department	323 East Hawkins Parkway	Longview	TX	Terminated
DSH450032M	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Labor & Delivery OP-Longview - Delivery Room & Labor Room	700 E Marshall Ave	Longview	TX	Terminated
DSH450032N	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Interventional Rad - Longview - Radiology - Diagnostic	700 E Marshall Ave	Longview	TX	Terminated
DSH450032P	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	ER - SANE - Longview - Emergency	700 E Marshall Ave	Longview	TX	Terminated
DSH450032Q	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Emergency Room - Longview - Emergency Room	700 E Marshall Ave	Longview	TX	Terminated
DSH450032R	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Computed Tomography - Longview - CT Scan	700 E Marshall Ave	Longview	TX	Terminated
DSH450032S	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Cath Lab - Longview - Cardiac Catheterization	700 E Marshall Ave	Longview	TX	Terminated
DSH450032T	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Cardio Pulmonary - Longview - Cardiopulmonary Rehab	700 E Marshall Ave	Longview	TX	Terminated
DSH450032U	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Blood Bank - Longview - Laboratory	700 E Marshall Ave	Longview	TX	Terminated
DSH450032V	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Infusion Clinic - Infusion Clinic	700 E Marshall Ave	Longview	TX	Terminated
DSH450032W	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	CHRISTUS TRINITY CLINIC - PAIN LGV	703 E. Marshall Ave	Longview	TX	Active
DSH450032X	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Center for Wound Healing and Hyperbaric Medicine - Wound Care	705 E. Marshall Ave	Longview	TX	Active
DSH450032Y	Child	DSH	GOOD SHEPHERD MEDICAL CENTER - MARSHALL	Breast Center at Good Shepherd - Longview - Radiology - Diagnostic	705 E. Marshall Ave	Longview	TX	Terminated
DSH450032Z	Child	DSH	GOOD SHEPHERD MEDICAL CENTER	Outpatient Imaging (701 E. Marshall location) - MRI	701 E. Marshall Ave	Longview	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	PC Change Request	Dudley, Drake Manager of Pharmacy Services Christus Health 9033152938	Georgiev, Jamie Lee Senior Pharmacy Buyer CHRISTUS Good Shepherd Medical Center 9033153127	12/26/2024 2:20 PM
Details	Last Recertification Date	Update	Recertification	8/31/2023 8:15:54 AM	8/28/2024 5:06:40 PM	8/28/2024 5:06 PM
Details	Last Recertification Date	Update	Recertification		8/31/2023 8:15:54 AM	8/31/2023 8:15 AM
Details	Entity Subname	Update	Recertification	CHRISTUS TRINITY CLINIC - ENT - ENT	CHRISTUS TRINITY CLINIC - ENT	8/31/2023 8:15 AM
Contacts	Primary Contact	Update	Group Change Request	Brown, Jonathan Director of Pharmacy Christus Good Shepherd Medical Center 9033152019	Dudley, Drake Manager of Pharmacy Services Christus Health 9033152938	6/16/2023 8:44 AM
Details	State	Update		Approved	Active	4/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Cheek, Michael CFO Good Shepherd Medical Center 9033151814	1/9/2023 6:46 AM
Details	340B ID	Update	New Registration		DSH450032CF	1/9/2023 6:46 AM
Details	Entity Subname	Update	New Registration	CHRISTUS TRINITY CLINIC - ENT	CHRISTUS TRINITY CLINIC - ENT - ENT	1/9/2023 6:46 AM
Dates	Participating Approval Date	Update	New Registration		1/9/2023 6:46:29 AM	1/9/2023 6:46 AM
Details	State	Update	New Registration	Pending	Approved	1/9/2023 6:46 AM
Dates	Signed By Date	Update	New Registration		1/5/2023 1:23:31 PM	1/9/2023 6:46 AM
Dates	Start Date	Update	New Registration		4/1/2023 12:00:00 AM	1/9/2023 6:46 AM
Addresses	Main Address	Insert	New Registration		705 E MARSHALL AVE STE 4003 Longview, TX 75601	1/3/2023 3:28 PM
Addresses	Billing Address	Insert	New Registration		GOOD SHEPHERD MEDICAL CENTER 700 E. MARSHALL AVENUE Longview, TX 75601	1/3/2023 3:28 PM
Addresses	Shipping Address	Insert	New Registration		GOOD SHEPHERD MEDICAL CENTER 700 E. MARSHALL AVENUE Longview, TX 75601	1/3/2023 3:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/3/2023 3:28 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1126674	1/3/2023 3:28 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	1/3/2023 3:28 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124092036	1/3/2023 3:28 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	1/3/2023 3:28 PM
Contacts	Primary Contact	Insert	New Registration		Brown, Jonathan Director of Pharmacy Christus Good Shepherd Medical Center 9033152019	1/3/2023 3:28 PM
Contacts	Authorizing Official	Insert	New Registration		Cheek, Michael CFO Good Shepherd Medical Center 9033151814	1/3/2023 3:28 PM
Details	Assistance Received From Date	Insert	New Registration			1/3/2023 3:28 PM
Details	Assistance Received To Date	Insert	New Registration			1/3/2023 3:28 PM
Details	Last Recertification Date	Insert	New Registration			1/3/2023 3:28 PM
Details	Grant Number	Insert	New Registration			1/3/2023 3:28 PM
Details	340B ID	Insert	New Registration			1/3/2023 3:28 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/3/2023 3:28 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/3/2023 3:28 PM
Details	Medicare Provider Number	Insert	New Registration		450032	1/3/2023 3:28 PM
Details	Entity Name	Insert	New Registration		GOOD SHEPHERD MEDICAL CENTER	1/3/2023 3:28 PM
Details	NOFO Number	Insert	New Registration			1/3/2023 3:28 PM
Details	Program Code	Insert	New Registration		DSH	1/3/2023 3:28 PM
Details	Entity Subname	Insert	New Registration		CHRISTUS TRINITY CLINIC - ENT	1/3/2023 3:28 PM
Dates	Participating Approval Date	Insert	New Registration			1/3/2023 3:28 PM
Details	State	Insert	New Registration		Pending	1/3/2023 3:28 PM
Dates	Registration Date	Insert	New Registration		1/3/2023 3:28:37 PM	1/3/2023 3:28 PM
Dates	Signed By Date	Insert	New Registration			1/3/2023 3:28 PM
Dates	Start Date	Insert	New Registration			1/3/2023 3:28 PM
Terminations	Termination Comments	Insert	New Registration			1/3/2023 3:28 PM
Terminations	Termination Date	Insert	New Registration			1/3/2023 3:28 PM
Terminations	Termination Effective Date	Insert	New Registration			1/3/2023 3:28 PM
Terminations	Termination Reason	Insert	New Registration			1/3/2023 3:28 PM