Covered Entity Details

DSH050599DV UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER (Active) - information as of 4/25/2025 5:38:58 PM

Main Details

Name

UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER

Subdivision Name

HBC Wound Care Ellison - HBC Wound Care Clinic Ellison

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050599DV

Medicare Provider Number

050599

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/12/2024

Participating Start Date

4/1/2024

Participating Approval Date

1/30/2024

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

UC Davis Health
Jennifer L Doll, Chief Financial Officer
(916) 708-2708

Primary Contact

UC Davis Medical Center
Mark Riggle, Assistant Chief Pharmacist
(916) 734-3309

Addresses

Street Address

4860 Y Street
Sacramento, CA 95817

Billing Address

UC Davis Medical Center Accounts Payable
PO Box 168016
Sacramento, CA 95816

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA		1710918545
NV		1710918545

Shipping Addresses

Shipping Address 1

University of California Davis Medical Center
2315 Stockton Blvd
Sacramento, CA 95817

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050599AA	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	SPINE CLINIC AT C STREET	3301 C STREET	Sacramento	CA	Active
DSH050599AB	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PHYSICIAL MEDICINE AND REHABILITATION OCCUPATIONAL THERAPY CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Terminated
DSH050599AC	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	VASCULAR CENTER LAB AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Terminated
DSH050599AD	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	HBC-RADIOLOGY-ELLISON ACC	4860 Y STREET	Sacramento	CA	Active
DSH050599AE	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	RADIOLOGY ULTRASOUND AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Terminated
DSH050599AF	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	MRI AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Terminated
DSH050599AG	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	NEUROLOGY CLINIC	3160 Folsom Blvd	Sacramento	CA	Active
DSH050599AH	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	NEUROSURGERY CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Terminated
DSH050599AJ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ENT SPEECH CLINIC AT GLASSROCK	2521 Stockton Blvd	Sacramento	CA	Active
DSH050599AK	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PHYSICAL MEDICINE AND REHABILITATION SPEECH THERAPY CLINIC AT GLASSROCK	2521 Stockton Blvd	Sacramento	CA	Terminated
DSH050599AL	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PHYSICAL MEDICINE AND REHABILITATION OCCUPATIONAL THERAPY CLINIC	2825 J STREET	Sacramento	CA	Terminated
DSH050599AM	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PHYSICAL MEDICINE AND REHABILITATION CLINIC	2825 J STREET	Sacramento	CA	Terminated
DSH050599AN	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	OPHTHALMOLOGY CLINIC AT UCDMG ROSEVILLE	2261 Douglas Blvd	Roseville	CA	Terminated
DSH050599AP	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	UCDMC HOME HEALTH	10850 White Rock Road	Rancho Cordova	CA	Active
DSH050599AQ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	UCDMC HOSPICE	10850 White Rock Road	Rancho Cordova	CA	Active
DSH050599AU	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	FAMILY PRACTICE CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599AX	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	CARDIAC REHABILITATION CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599AY	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	CARDIOLOGY CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599AZ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	CT HEAD AND BODY SCANNING CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Terminated
DSH050599B	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	CANCER CENTER	4501 X STREET	SACRAMENTO	CA	Terminated
DSH050599BB	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	DERMATOLOGY CLINIC AT FOLSOM	1370 Prairie City Road	Folsom	CA	Terminated
DSH050599BC	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	GENERAL INTERNAL MEDICINE CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599BD	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	J STREET MEDICAL SPECIALTY CLINIC	2825 J Street	Sacramento	CA	Active
DSH050599BF	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	OPHTHALMOLOGY CLINIC AT CADILLAC DRIVE	77 Cadillac Drive	Sacramento	CA	Terminated
DSH050599BG	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	MIND INSTITUTE CLINIC	2825 50th Street	Sacramento	CA	Active
DSH050599BH	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	NEUROSCIENCE CLINIC AT AMBULATORY CARE CENTER	4860 Y Street	Sacramento	CA	Terminated
DSH050599BJ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	NON-INVASIVE VASCULAR LAB AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Terminated
DSH050599BK	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	OBSTETRICS AND GYNECOLOGY CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599BL	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ORTHOPEDICS CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599BM	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PAIN CLINIC AT AMBULATORY CARE CENTER	4860 Y Street	Sacramento	CA	Active
DSH050599BN	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PHYSICAL MEDICINE AND REHABILITATION CLINIC	4860 Y STREET	Sacramento	CA	Active
DSH050599BP	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PHYSICAL MEDICINE AND REHABILITATION HAND THERAPY CLINIC	4860 Y STREET	Sacramento	CA	Terminated
DSH050599BQ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PHYSICAL MEDICINE AND REHABILITATION PHYSICAL THERAPY CLINIC	4860 Y STREET	Sacramento	CA	Terminated
DSH050599BR	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	RADIOLOGY DIAGNOSTICS AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Terminated
DSH050599BT	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	OPHTHALMOLOGY CLINIC	4860 Y STREET	Sacramento	CA	Active
DSH050599BU	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	UROLOGY CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599BV	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ENT Procedures	2521 Stockton Blvd	Sacramento	CA	Active
DSH050599BW	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PET Radiology Clinic (ACC)	4860 Y Street	Sacramento	CA	Terminated
DSH050599BX	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ANESTHESIOLOGY / ANESTHESIOLOGY GLASSROCK	2521 STOCKTON BLVD, STE 5200	SACRAMENTO	CA	Terminated
DSH050599BY	Child	DSH	UC DAVIS MEDICAL CENTER	UNIVERSITY WOMENS CLINIC / BREAST HEALTH CENTER	4860 Y STREET, STE 0540	SACRAMENTO	CA	Terminated
DSH050599BZ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PLACER CENTER FOR HEALTH / ROCKLIN INFUSION	550 WEST RANCH VIEW DR	ROCKLIN	CA	Active
DSH050599CA	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PM&R SPINE CENTER / PHYSICAL THERAPY	3301 C ST	SACRAMENTO	CA	Active
DSH050599CB	Child	DSH	UC DAVIS MEDICAL CENTER	Ophthalmology Clinic / Ophthalmology	251 Turnpike Dr, Ste 1070	Folsom	CA	Terminated
DSH050599CC	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Speech Pathology / PM&R Speech Therapy	4860 Y Street	Sacramento	CA	Terminated
DSH050599CD	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Adult IV Infusion Center 3rd Floor	2279 45th St	Sacramento	CA	Active
DSH050599CE	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Pediatric IV Infusion Center	2279 45th St	Sacramento	CA	Active
DSH050599CF	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cancer Center Clinic / BMT Transplant Program	2279 45th St	Sacramento	CA	Terminated
DSH050599CG	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cancer Center Clinic / Pediatrics Cancer Center Clinic	2279 45th St	Sacramento	CA	Terminated
DSH050599CH	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cancer Center / Cancer Center Clinics	2279 45th St	Sacramento	CA	Active
DSH050599CJ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cancer Center / Radiation Oncology	4501 X St	Sacramento	CA	Active
DSH050599CK	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	UC DAVIS MEDICAL CENTER / CT Head and Body Scanning at Glassrock	2521 Stockton Blvd	SACRAMENTO	CA	Active
DSH050599CL	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	UC DAVIS MEDICAL CENTER / RADIOLOGY SPINE CLINIC	3301 C ST	SACRAMENTO	CA	Active
DSH050599CM	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	UC DAVIS MEDICAL CENTER / PM&R EMG LABORATORY	4860 Y STREET	SACRAMENTO	CA	Active
DSH050599CN	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	CANCER CENTER CLINIC / ADULT IV INFUSION CENTER	4501 X STREET	SACRAMENTO	CA	Active
DSH050599CP	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ADULT INFUSION / GLASSROCK INFUSION	2521 STOCKTON BLVD	SACRAMENTO	CA	Terminated
DSH050599CQ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	MEDICAL GI SPECIALTY CLINIC - SACTO CLINIC / GI	3160 Folsom Blvd	SACRAMENTO	CA	Active
DSH050599CR	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PEDIATRIC NEUROLOGY	3160 Folsom Blvd	SACRAMENTO	CA	Active
DSH050599CS	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	SLEEP LAB	3160 Folsom Blvd	SACRAMENTO	CA	Active
DSH050599CT	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ELECTROMYOGRAPHY	3160 Folsom Blvd	SACRAMENTO	CA	Active
DSH050599CU	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ELECTROENCEPHALOGRAPHY	3160 Folsom Blvd	SACRAMENTO	CA	Active
DSH050599CV	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Gastroenterology Glassrock / GLASSROCK NON-CHEMOTHERAPY INFUSION	2521 STOCKTON BLVD	SACRAMENTO	CA	Terminated
DSH050599CW	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	OTOLARYGOLOGY GLASSROCK / REFLUX CLINIC	2521 STOCKTON BLVD	SACRAMENTO	CA	Terminated
DSH050599CX	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cancer Center / BMT Transplant Program	4501 X St	SACRAMENTO	CA	Terminated
DSH050599CY	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cancer Center Clinic	4501 X Street	SACRAMENTO	CA	Active
DSH050599CZ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	NEUROSCIENCES CLINIC / NEUROSURGERY CLINIC	3160 FOLSOM BLVD	SACRAMENTO	CA	Active
DSH050599DA	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ALZHEIMERS DISEASE AND DIAGNOSTIC TREATMENT CENTER	4860 Y ST	SACRAMENTO	CA	Terminated
DSH050599DB	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	SPORTS MEDICINE CLINIC	3301 C ST	SACRAMENTO	CA	Active
DSH050599DC	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	SURGERY PEDIATRIC GLASSROCK	2521 STOCKTON BLVD	SACRAMENTO	CA	Terminated
DSH050599DE	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Midtown Multispecialty Clinic - Multispecialty	3160 Folsom Blvd	Sacramento	CA	Terminated
DSH050599DF	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	MIDTOWN GI LAB - GI	3160 Folsom Blvd	Sacramento	CA	Active
DSH050599DG	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Radiology Midtown Imaging - Radiology	3160 Folsom Blvd	Sacramento	CA	Active
DSH050599DH	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	UC DAVIS MEDICAL CENTER - PAIN SERVICE CLINIC	3301 C ST	SACRAMENTO	CA	Active
DSH050599DJ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	GYNECOLOGY CLINIC - Midtown OB	3160 Folsom Blvd	Sacramento	CA	Terminated
DSH050599DK	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PEDIATRIC CANCER CENTER - Pediatric Oncology	2279 45th Street	Sacramento	CA	Active
DSH050599DL	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ENT PEDIATRICS - OTOLARYNGOLOGY CLINIC PEDIATRICS	2521 STOCKTON BLVD	SACRAMENTO	CA	Terminated
DSH050599DM	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	UC DAVIS MEDICAL CENTER - PULMONARY REHAB J ST	2825 J Street	Sacramento	CA	Active
DSH050599DN	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Apheresis/Vascular Access - Apheresis Services	2521 Stockton Blvd	Sacramento	CA	Active
DSH050599DP	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Operating Room - Surgical Admission Center	4860 Y Street	Sacramento	CA	Active
DSH050599DQ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cardiac Cath Lab - PHC Echocardiography Lab	4860 Y Street	Sacramento	CA	Active
DSH050599DR	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cancer Center Clinic - Supportive Oncology Services	4501 X St	Sacramento	CA	Active
DSH050599DS	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Cancer Center Clinic - Supportive Oncology Services	2279 45th St	Sacramento	CA	Active
DSH050599DT	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Pain Service Clinic - Pain Clinic at TEI	4860 Y Street	Sacramento	CA	Active
DSH050599DU	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Pain Service Clinic - AIM Services Glassrock	2521 Stockton Blvd	Sacramento	CA	Terminated
DSH050599DV	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	HBC Wound Care Ellison - HBC Wound Care Clinic Ellison	4860 Y Street	Sacramento	CA	Active
DSH050599DW	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Pediatric Specialist Clinic - Pediatric Ambulatory Service Clinic	77 Cadillac Dr	Sacramento	CA	Active
DSH050599DX	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Electrocardiology - Cardiac Cath Lab - PHC Echocardiography Lab	77 Cadillac Dr	Sacramento	CA	Active
DSH050599DY	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PAIN SERVICE CLINIC - AIM SERVICES	2279 45th Street	Sacramento	CA	Active
DSH050599DZ	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Bone Marrow Transplant - Cancer Center Clinics -Benign Hematology	3301 C Street	Sacramento	CA	Terminated
DSH050599F	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	SURGERY CLINIC	2221 Stockton Blvd	Sacramento	CA	Active
DSH050599FA	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Physical Therapy - PM&R TRAUMATC BRAIN INJURY	4860 Y Street	Sacramento	CA	Active
DSH050599FB	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	Psychiatry BHC - ADV PSYCH THRPY CLINIC-ACC	4860 Y Street	Sacramento	CA	Active
DSH050599H	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	TRANSPLANT CLINIC	2221 Stockton Blvd	Sacramento	CA	Active
DSH050599K	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	SPECIALTY INTERNAL MEDICINE CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599L	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	OBSTETRICS AND GYNECOLOGY CLINIC AT GLASSROCK	2521 Stockton Blvd	Sacramento	CA	Terminated
DSH050599M	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	HBC - Otolaryngology Clinic - Glassrock	2521 Stockton Blvd	Sacramento	CA	Active
DSH050599N	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	DENTAL CLINIC AT GLASSROCK	2521 Stockton Blvd	Sacramento	CA	Active
DSH050599P	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PEDIATRIC INFUSION CENTER AT GLASSROCK	2521 Stockton Blvd	Sacramento	CA	Terminated
DSH050599R	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	ENT AUDIOLOGY CLINIC AT GLASSROCK	2521 Stockton Blvd	Sacramento	CA	Active
DSH050599S	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PEDIATRIC CARDIOLOGY CLINIC	2521 Stockton Blvd	Sacramento	CA	Terminated
DSH050599T	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PEDIATRIC AMBULATORY SERVICE CLINIC AT GLASSROCK	2521 Stockton Blvd	Sacramento	CA	Active
DSH050599U	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	SAME DAY SURGERY CENTER	4845 2ND AVE	SACRAMENTO	CA	Active
DSH050599V	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	GI OUTREACH AT PLACER CENTER FOR HEALTH	550 W. Ranch View Dr.	ROCKLIN	CA	Active
DSH050599W	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	VASCULAR CENTER CLINIC AT AMBULATORY CARE CENTER	4860 Y STREET	Sacramento	CA	Active
DSH050599X	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	RADIOLOGY AT PLACER CENTER FOR HEALTH	550 W. Ranch View Dr.	Rocklin	CA	Active
DSH050599Y	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	DERMATOLOGY CLINIC AT C STREET	3301 C Street	Sacramento	CA	Active
DSH050599Z	Child	DSH	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	PLASTIC SURGERY CLINIC AT C STREET	3301 C STREET	Sacramento	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700804200 (CA)		11/4/2024 6:22 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700804200 (NV)		11/4/2024 6:22 PM
Contacts	Authorizing Official	Update	AO Change Request	Sousa, Noel Interim CFO UC Davis Health 9164967593	Doll, Jennifer L Chief Financial Officer UC Davis Health 9167082708	9/12/2024 7:19 AM
Details	Last Recertification Date	Update	Recertification		8/22/2024 2:11:10 PM	8/22/2024 2:11 PM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Sousa, Noel Interim CFO UC Davis Health 9164967593	1/30/2024 7:12 AM
Details	340B ID	Update	New Registration		DSH050599DV	1/30/2024 7:12 AM
Details	Entity Name	Update	New Registration	UC DAVIS MEDICAL CENTER	UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER	1/30/2024 7:12 AM
Details	Entity Subname	Update	New Registration	HBC Wound Care Ellison	HBC Wound Care Ellison - HBC Wound Care Clinic Ellison	1/30/2024 7:12 AM
Dates	Participating Approval Date	Update	New Registration		1/30/2024 7:12:15 AM	1/30/2024 7:12 AM
Details	State	Update	New Registration	Pending	Approved	1/30/2024 7:12 AM
Dates	Signed By Date	Update	New Registration		1/29/2024 2:31:33 AM	1/30/2024 7:12 AM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	1/30/2024 7:12 AM
Addresses	Main Address	Insert	New Registration		4860 Y Street Sacramento, CA 95817	1/12/2024 6:46 PM
Addresses	Billing Address	Insert	New Registration		UC Davis Medical Center Accounts Payable PO Box 168016 Sacramento, CA 95816	1/12/2024 6:46 PM
Addresses	Shipping Address	Insert	New Registration		University of California Davis Medical Center 2315 Stockton Blvd Sacramento, CA 95817	1/12/2024 6:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710918545	1/12/2024 6:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	1/12/2024 6:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700804200	1/12/2024 6:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	1/12/2024 6:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710918545	1/12/2024 6:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	1/12/2024 6:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700804200	1/12/2024 6:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	1/12/2024 6:46 PM
Contacts	Primary Contact	Insert	New Registration		Riggle, Mark Assistant Chief Pharmacist UC Davis Medical Center 9167343309	1/12/2024 6:46 PM
Contacts	Authorizing Official	Insert	New Registration		Sousa, Noel Interim CFO UC Davis Health 9164967593	1/12/2024 6:46 PM
Details	Assistance Received From Date	Insert	New Registration			1/12/2024 6:46 PM
Details	Assistance Received To Date	Insert	New Registration			1/12/2024 6:46 PM
Details	Last Recertification Date	Insert	New Registration			1/12/2024 6:46 PM
Details	Grant Number	Insert	New Registration			1/12/2024 6:46 PM
Details	340B ID	Insert	New Registration			1/12/2024 6:46 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/12/2024 6:46 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/12/2024 6:46 PM
Details	Medicare Provider Number	Insert	New Registration		050599	1/12/2024 6:46 PM
Details	Entity Name	Insert	New Registration		UC DAVIS MEDICAL CENTER	1/12/2024 6:46 PM
Details	NOFO Number	Insert	New Registration			1/12/2024 6:46 PM
Details	Program Code	Insert	New Registration		DSH	1/12/2024 6:46 PM
Details	Entity Subname	Insert	New Registration		HBC Wound Care Ellison	1/12/2024 6:46 PM
Dates	Participating Approval Date	Insert	New Registration			1/12/2024 6:46 PM
Details	State	Insert	New Registration		Pending	1/12/2024 6:46 PM
Dates	Registration Date	Insert	New Registration		1/12/2024 6:46:17 PM	1/12/2024 6:46 PM
Dates	Signed By Date	Insert	New Registration			1/12/2024 6:46 PM
Dates	Start Date	Insert	New Registration			1/12/2024 6:46 PM
Terminations	Termination Comments	Insert	New Registration			1/12/2024 6:46 PM
Terminations	Termination Date	Insert	New Registration			1/12/2024 6:46 PM
Terminations	Termination Effective Date	Insert	New Registration			1/12/2024 6:46 PM
Terminations	Termination Reason	Insert	New Registration			1/12/2024 6:46 PM