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DSH450018A UNIVERSITY OF TEXAS MEDICAL BRANCH (Active)
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Main Details
Name
UNIVERSITY OF TEXAS MEDICAL BRANCH
Subdivision Name
UTMB - CMC CLINIC
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH450018A
Medicare Provider Number
450018
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
11/29/2007
Participating Start Date
4/1/2002
Participating Approval Date
11/29/2007
Last Recertification Date
8/20/2024
Contacts
Authorizing Official
UTMB
Carolanda B Woodgett, Senior Vice President and Chief Legal Officer
(409) 747-8735
Primary Contact
University of Texas Medical Branch
Stephanie Zepeda, Assoc VP, Pharmacy Services
(936) 437-5363
Addresses
Street Address
2400 AVENUE I
HUNTSVILLE, TX 77340
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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2/7/08 ADDED MED # ; 8/29/06 REMOVED IPS (REPACKAGER) AS SHIP TO ADDRESS; 3/27/06 NEW ADDR (WAS TDCJ DEPT OF PHARMACY, 264 FM 3478, ESTELLE UNIT, HUNTSVILLE, TX 77320); 5/17/04 ADDED SHIP TO, NEW MEDICAID # (WAS HO45-00189)
11/29/2007
April 2025
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