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PED453302-05 CHILDREN'S MEDICAL CENTER DALLAS (Terminated)
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Main Details
Name
CHILDREN'S MEDICAL CENTER DALLAS
Subdivision Name
MESQUITE SPECIALTY CENTER
Type
Children's Hospital
Rural
No
340B ID
PED453302-05
Medicare Provider Number
453302
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
3/25/2010
Participating Start Date
4/1/2010
Participating Approval Date
3/25/2010
Last Recertification Date
8/15/2016
Termination Date
Termination Reason
4/1/2017
Site closure
Contacts
Authorizing Official
Children's Health
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Primary Contact
Children's Health System of Texas
Michelle Kromelis, Senior Director of Pharmacy
(214) 456-6203
Addresses
Street Address
1600 REPUBLIC PKWY
SUITE 100
MESQUITE, TX 75150
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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