340B Drug Pricing Program Database
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PED453300-26 COOK CHILDREN'S MEDICAL CENTER (Terminated)
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Main Details
Name
COOK CHILDREN'S MEDICAL CENTER
Subdivision Name
Dodson Specialty Clinic ~ Neuro Psych
Type
Children's Hospital
Rural
No
340B ID
PED453300-26
Medicare Provider Number
453300
Outpatient Facility Provider Number
453300
Additional Details
Current Program Status
Terminated
Registration Date
11/22/2013
Participating Start Date
1/1/2014
Participating Approval Date
12/12/2013
Last Recertification Date
8/20/2018
Termination Date
Termination Reason
7/1/2019
Business decision by the Covered Entity
Contacts
Authorizing Official
Cook Children's Medical Center
Nancy Cychol, EVP, Hospital Services
(682) 885-4340
Primary Contact
Cook Children's Medical Center
Adriana Martinez, 340B Program Manager
(682) 885-2167
Addresses
Street Address
1500 Cooper St
Fort Worth, TX 76104
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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June 2025
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