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DSH450068CG Memorial Hermann Texas Medical Center (Terminated)
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Main Details
Name
Memorial Hermann Texas Medical Center
Subdivision Name
TMC-Transplant Clinic - Transplant
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH450068CG
Medicare Provider Number
450068
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
11/18/2021
Participating Start Date
1/1/2022
Participating Approval Date
11/23/2021
Last Recertification Date
Termination Date
Termination Reason
7/1/2022
Outpatient facility moved within the 4 walls of the parent hospital
Contacts
Authorizing Official
Memorial Hermann Health System
Jessica Ann Graham, Chief Financial Officer
(843) 408-6835
Primary Contact
Memorial Hermann
Eric John Wucki, Director of Pharmacy-340B
(262) 527-2475
Addresses
Street Address
6410 Fannin St, Suite 225
Houston, TX 77030
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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