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DSH450068AA MEMORIAL HERMANN TEXAS MEDICAL CNTR (Terminated)
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Main Details
Name
MEMORIAL HERMANN TEXAS MEDICAL CNTR
Subdivision Name
TMC Breast Center
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH450068AA
Medicare Provider Number
450068
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/13/2015
Participating Start Date
1/1/2016
Participating Approval Date
11/5/2015
Last Recertification Date
9/5/2016
Termination Date
Termination Reason
1/1/2018
Other
Contacts
Authorizing Official
Memorial Hermann TMC
Bryan Lee, VP, Finance
(713) 704-4710
Primary Contact
Memorial Hermann System
Jo Ann Maack, System Pharmacy Director
(713) 242-2814
Addresses
Street Address
6400 Fannin, #1600
Houston, TX 77030
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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May 2025
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