340B Drug Pricing Program Database

Name

COOK CHILDREN'S MEDICAL CENTER

Subdivision Name

Alexander Vision Center ~ Ophthalmology

Type

Children's Hospital

Rural

No

340B ID

PED453300-40

Medicare Provider Number

453300

Outpatient Facility Provider Number

Current Program Status

Terminated

Registration Date

1/13/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/14/2015

Last Recertification Date

11/9/2017

Termination Date
Termination Reason

7/1/2018
Business decision by the Covered Entity

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

Street Address

321 S. Henderson St
Fort Worth, TX 76104

Billing Address

Cook Childrens Medical Center
801 7th Ave
Fort Worth, TX 76104