Covered Entity Details

DSH450571C SHANNON MEDICAL CENTER (Terminated)

Main Details

Name

SHANNON MEDICAL CENTER

Subdivision Name

SHANNON ADULT OP CHEMO CLINIC

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH450571C

Medicare Provider Number

450571

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/5/2016

Participating Start Date

1/1/2017

Participating Approval Date

11/16/2016

Last Recertification Date

Termination Date
Termination Reason

4/1/2017
DSH percentage below statutory minimum

Contacts

Authorizing Official

Staci Wetz, Chief Financial Officer
(325) 481-8416

Primary Contact

Shannon Medical Center
Steve Lubke, Director of Pharmacy Services
(325) 657-5189

Addresses

Street Address

102 N. MAGDALEN
SAN ANGELO, TX 76903

Billing Address

Shannon Medical Center
120 E. Harris Ave
San Angelo, TX 76903

Comment	Last Updated On
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11/16/16 Participating starting 7/1/2015 until terminated effective 4/1/2016, reinstated 1/1/2017.	11/16/2016
5/28/15 CE reinstated effective 7/1/2015, was participating from 7/1/2008 to 6/30/2013, not participating from 7/1/2013 to 6/30/2015 due to DSH percentage below statutory minimum.	05/28/2015
7/17/13-This child site became ineligible as of July 1, 2013, the same day as the parent. The parent reported a DSH percentage that dropped below the statutory minimum threshold.10/12/11 REMOVED NPI # (WAS 1992707228); 9/27/07- DOC RECD TO CONFIRM ELIG DSH ADJ %	07/18/2013
10/12/11 REMOVED NPI # (WAS 1992707228); 9/27/07- DOC RECD TO CONFIRM ELIG DSH ADJ %	10/12/2011
9/27/07- DOC RECD TO CONFIRM ELIG DSH ADJ %	06/04/2008

340B Drug Pricing Program Database