Covered Entity Details

RRC450023-01 CITIZENS MEDICAL CENTER (Active) - information as of 5/10/2025 10:54:58 PM

Main Details

Name

CITIZENS MEDICAL CENTER

Subdivision Name

CITIZENS HEALTH PLEX - Physical Rehab

Type

Rural Referral Center

Rural

340B ID

RRC450023-01

Medicare Provider Number

450023

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/7/2023

Participating Start Date

7/1/2023

Participating Approval Date

5/24/2023

Last Recertification Date

9/9/2024

Contacts

Authorizing Official

Citizens Medical Center
Duane L. Woods, CFO
(361) 572-5009

Primary Contact

Citizens Medical Center
Michael Casas, Directory of Pharmacy
(361) 572-5071

Addresses

Street Address

9406 NE ZAC LENTZ PKWY
VICTORIA, TX 77904-3108

Billing Address

Citizens Medical Center
2701 Hospital Drive
Victoria, TX 77901

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	137907508; 137907506;	1124052162

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
RRC450023-01	Child	RRC	CITIZENS MEDICAL CENTER	CITIZENS HEALTH PLEX - Physical Rehab	9406 NE ZAC LENTZ PKWY	VICTORIA	TX	Active
RRC450023-02	Child	RRC	CITIZENS MEDICAL CENTER	CITIZENS HEALTH PLEX - Cardiac Rehab	9406 NE ZAC LENTZ PKWY	VICTORIA	TX	Active
RRC450023-03	Child	RRC	CITIZENS MEDICAL CENTER	CITIZENS HEALTH PLEX - Respiratory Therapy	9406 NE ZAC LENTZ PKWY	VICTORIA	TX	Active
RRC450023-04	Child	RRC	CITIZENS MEDICAL CENTER	CITIZENS IMAGING CENTER - Imaging	9410 N. ZAC LENTZ PKWY	VICTORIA	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 4:40:37 PM	9/9/2024 9:38:35 AM	9/9/2024 9:38 AM
Details	Last Recertification Date	Update	Recertification		8/15/2023 4:40:37 PM	8/15/2023 4:40 PM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Woods, Duane L. CFO Citizens Medical Center 3615725009	5/24/2023 6:51 AM
Details	340B ID	Update	New Registration		RRC450023-01	5/24/2023 6:51 AM
Details	Entity Subname	Update	New Registration	CITIZENS HEALTH PLEX	CITIZENS HEALTH PLEX - Physical Rehab	5/24/2023 6:51 AM
Dates	Participating Approval Date	Update	New Registration		5/24/2023 6:51:03 AM	5/24/2023 6:51 AM
Details	State	Update	New Registration	Pending	Approved	5/24/2023 6:51 AM
Dates	Signed By Date	Update	New Registration		4/7/2023 11:53:05 AM	5/24/2023 6:51 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	5/24/2023 6:51 AM
Addresses	Main Address	Insert	New Registration		9406 NE ZAC LENTZ PKWY VICTORIA, TX 77904-3108	4/7/2023 11:53 AM
Addresses	Billing Address	Insert	New Registration		Citizens Medical Center 2701 Hospital Drive Victoria, TX 77901	4/7/2023 11:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2023 11:53 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		137907508; 137907506;	4/7/2023 11:53 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/7/2023 11:53 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124052162	4/7/2023 11:53 AM
Medicaid Billing	NPI: State	Insert	New Registration		TX	4/7/2023 11:53 AM
Contacts	Authorizing Official	Insert	New Registration		Woods, Duane L. CFO Citizens Medical Center 3615725009	4/7/2023 11:53 AM
Contacts	Primary Contact	Insert	New Registration		Casas, Michael Directory of Pharmacy Citizens Medical Center 3615725071	4/7/2023 11:53 AM
Details	Assistance Received From Date	Insert	New Registration			4/7/2023 11:53 AM
Details	Assistance Received To Date	Insert	New Registration			4/7/2023 11:53 AM
Details	Last Recertification Date	Insert	New Registration			4/7/2023 11:53 AM
Details	Grant Number	Insert	New Registration			4/7/2023 11:53 AM
Details	340B ID	Insert	New Registration			4/7/2023 11:53 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/7/2023 11:53 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/7/2023 11:53 AM
Details	Medicare Provider Number	Insert	New Registration		450023	4/7/2023 11:53 AM
Details	Entity Name	Insert	New Registration		CITIZENS MEDICAL CENTER	4/7/2023 11:53 AM
Details	NOFO Number	Insert	New Registration			4/7/2023 11:53 AM
Details	Program Code	Insert	New Registration		RRC	4/7/2023 11:53 AM
Details	Entity Subname	Insert	New Registration		CITIZENS HEALTH PLEX	4/7/2023 11:53 AM
Dates	Participating Approval Date	Insert	New Registration			4/7/2023 11:53 AM
Details	State	Insert	New Registration		Pending	4/7/2023 11:53 AM
Dates	Registration Date	Insert	New Registration		4/7/2023 11:53:00 AM	4/7/2023 11:53 AM
Dates	Signed By Date	Insert	New Registration			4/7/2023 11:53 AM
Dates	Start Date	Insert	New Registration			4/7/2023 11:53 AM
Terminations	Termination Comments	Insert	New Registration			4/7/2023 11:53 AM
Terminations	Termination Date	Insert	New Registration			4/7/2023 11:53 AM
Terminations	Termination Effective Date	Insert	New Registration			4/7/2023 11:53 AM
Terminations	Termination Reason	Insert	New Registration			4/7/2023 11:53 AM