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DSH450068BQ MEMORIAL HERMANN TEXAS MEDICAL CNTR (Terminated)
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Main Details
Name
MEMORIAL HERMANN TEXAS MEDICAL CNTR
Subdivision Name
Memorial Hermann Cypress - Outpatient Observation Unit - Observation Unit
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH450068BQ
Medicare Provider Number
450068
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/11/2018
Participating Start Date
7/1/2018
Participating Approval Date
5/21/2018
Last Recertification Date
9/10/2018
Termination Date
Termination Reason
10/1/2019
Other
Contacts
Authorizing Official
Memorial Hermann TMC
Bryan Lee, VP, Finance
(713) 704-4710
Primary Contact
Memorial Hermann
Illiana Rangel, 340B Manager
(713) 242-2858
Addresses
Street Address
27800 Northwest Freeway
Cypress, TX 77433
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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