Covered Entity Details

DSH450610N MEMORIAL HERMANN MEMORIAL CITY MEDIC (Active) - information as of 5/7/2025 10:43:22 PM

Main Details

Name

MEMORIAL HERMANN MEMORIAL CITY MEDIC

Subdivision Name

Memorial Hermann Memorial City Medical Center - Outpatient Ultrasound

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450610N

Medicare Provider Number

450610

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/10/2023

Participating Start Date

7/1/2023

Participating Approval Date

5/22/2023

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Memorial Hermann
Robert C Ogden, Associate Vice President of Finance
(713) 456-5111

Primary Contact

Memorial Hermann
Eric John Wucki, Director of Pharmacy-340B
(262) 527-2475

Addresses

Street Address

925 Gessner Rd. Suite 200
Houston, TX 77024

Billing Address

Memorial Hermann
929 Gessner Rd, Suite 2690
Houston, TX 77024

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	020934801	1740233782

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
DSH450610A	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Cardiac Rehab	915 Gessner Rd.	Houston	TX	Active
DSH450610AA	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Ortho Recovery	929 Gessner Rd.	Houston	TX	Active
DSH450610AB	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Burbank Clinic - School Clinic	315 Berry Rd	Houston	TX	Terminated
DSH450610B	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Radiation Therapy	925 Gessner rd. Suite 100	Houston	TX	Active
DSH450610C	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Endoscopy	920 Frostwood Dr.	Houston	TX	Active
DSH450610D	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Wound Care	920 Frostwood Dr.	Houston	TX	Active
DSH450610E	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Outpatient Surgery	920 Frostwood Dr.	Houston	TX	Active
DSH450610F	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Maternity Care	929 Gessner Dr.	Houston	TX	Active
DSH450610G	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Sleep Lab	929 Gessner Dr.	Houston	TX	Terminated
DSH450610H	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Pediatric Sleep Lab	929 Gessner Dr.	Houston	TX	Terminated
DSH450610J	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Ortho OR	929 Gessner rd	Houston	TX	Active
DSH450610K	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Pelvic Floor Center	929 Gessner Rd.	Houston	TX	Active
DSH450610L	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Cy-Fair Mammography	13114 FM 1960 Suite 104	Houston	TX	Active
DSH450610M	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Hedwig MRI	9418 Gaylord dr	Houston	TX	Active
DSH450610N	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Outpatient Ultrasound	925 Gessner Rd. Suite 200	Houston	TX	Active
DSH450610P	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Outpatient MRI	925 Gessner Rd. Suite 200	Houston	TX	Active
DSH450610Q	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Hedwig Ultrasound	9418 Gaylord dr	Houston	TX	Active
DSH450610R	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Cy-Fair-NUCLEAR MEDICINE	13114 FM 1960 Suite 104	Houston	TX	Active
DSH450610S	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Outpatient Nuclear Medicine	925 Gessner Rd. Suite 200	Houston	TX	Active
DSH450610T	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Outpatient CT	925 Gessner Rd. Suite 200	Houston	TX	Active
DSH450610U	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Cy-Fair Ultrasound	13114 FM 1960 Suite 104	Houston	TX	Active
DSH450610V	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Outpatient PET Scan	925 Gessner Rd. Suite 200	Houston	TX	Active
DSH450610W	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Outpatient Radiology	925 Gessner Rd. Suite 300	Houston	TX	Active
DSH450610X	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Cy-Fair MRI	13114 FM 1960 Suite 104	Houston	TX	Active
DSH450610Y	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Cy-Fair CT	13114 FM 1960 Suite 104	Houston	TX	Active
DSH450610Z	Child	DSH	MEMORIAL HERMANN MEMORIAL CITY MEDIC	Memorial Hermann Memorial City Medical Center - Hedwig CT	9418 Gaylord dr.	Houston	TX	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 2:46:23 PM	8/29/2024 4:58:46 PM	8/29/2024 4:58 PM
Contacts	Primary Contact	Update	Profile Change Request	Wucki, Eric John 340B Manager Memorial Hermann 2625272475	Wucki, Eric John Director of Pharmacy-340B Memorial Hermann 2625272475	8/5/2024 1:13 PM
Details	Last Recertification Date	Update	Recertification		9/5/2023 2:46:23 PM	9/5/2023 2:46 PM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Ogden, Robert C Associate Vice President of Finance Memorial Hermann 7134565111	5/22/2023 2:40 PM
Details	340B ID	Update	New Registration		DSH450610N	5/22/2023 2:40 PM
Details	Entity Subname	Update	New Registration	Memorial Hermann Memorial City Medical Center	Memorial Hermann Memorial City Medical Center - Outpatient Ultrasound	5/22/2023 2:40 PM
Dates	Participating Approval Date	Update	New Registration		5/22/2023 2:40:01 PM	5/22/2023 2:40 PM
Details	State	Update	New Registration	Pending	Approved	5/22/2023 2:40 PM
Dates	Signed By Date	Update	New Registration		5/12/2023 3:49:54 PM	5/22/2023 2:40 PM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	5/22/2023 2:40 PM
Addresses	Main Address	Insert	New Registration		925 Gessner Rd. Suite 200 Houston, TX 77024	4/10/2023 5:36 PM
Addresses	Billing Address	Insert	New Registration		Memorial Hermann 929 Gessner Rd, Suite 2690 Houston, TX 77024	4/10/2023 5:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/10/2023 5:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		020934801	4/10/2023 5:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/10/2023 5:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1740233782	4/10/2023 5:36 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	4/10/2023 5:36 PM
Contacts	Authorizing Official	Insert	New Registration		Ogden, Robert C Associate Vice President of Finance Memorial Hermann 7134565111	4/10/2023 5:36 PM
Contacts	Primary Contact	Insert	New Registration		Wucki, Eric John 340B Manager Memorial Hermann 2625272475	4/10/2023 5:36 PM
Details	Assistance Received From Date	Insert	New Registration			4/10/2023 5:36 PM
Details	Assistance Received To Date	Insert	New Registration			4/10/2023 5:36 PM
Details	Last Recertification Date	Insert	New Registration			4/10/2023 5:36 PM
Details	Grant Number	Insert	New Registration			4/10/2023 5:36 PM
Details	340B ID	Insert	New Registration			4/10/2023 5:36 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/10/2023 5:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/10/2023 5:36 PM
Details	Medicare Provider Number	Insert	New Registration		450610	4/10/2023 5:36 PM
Details	Entity Name	Insert	New Registration		MEMORIAL HERMANN MEMORIAL CITY MEDIC	4/10/2023 5:36 PM
Details	NOFO Number	Insert	New Registration			4/10/2023 5:36 PM
Details	Program Code	Insert	New Registration		DSH	4/10/2023 5:36 PM
Details	Entity Subname	Insert	New Registration		Memorial Hermann Memorial City Medical Center	4/10/2023 5:36 PM
Dates	Participating Approval Date	Insert	New Registration			4/10/2023 5:36 PM
Details	State	Insert	New Registration		Pending	4/10/2023 5:36 PM
Dates	Registration Date	Insert	New Registration		4/10/2023 5:36:07 PM	4/10/2023 5:36 PM
Dates	Signed By Date	Insert	New Registration			4/10/2023 5:36 PM
Dates	Start Date	Insert	New Registration			4/10/2023 5:36 PM
Terminations	Termination Comments	Insert	New Registration			4/10/2023 5:36 PM
Terminations	Termination Date	Insert	New Registration			4/10/2023 5:36 PM
Terminations	Termination Effective Date	Insert	New Registration			4/10/2023 5:36 PM
Terminations	Termination Reason	Insert	New Registration			4/10/2023 5:36 PM