No
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 486492 145677 (AZ) | | 3/10/2025 5:27 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1164751285 (AZ) | | 3/10/2025 5:27 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1487399937 (AZ) | | 3/10/2025 5:27 PM |
| Addresses | Billing Address | Insert | Recertification | | Ajo Community Health Center
410 N Malacate St
Ajo, AZ 85321 | 2/11/2025 1:40 PM |
| Details | Last Recertification Date | Update | Recertification | | 2/11/2025 1:40:57 PM | 2/11/2025 1:40 PM |
| Details | State | Update | | Approved | Active | 7/1/2024 12:01 AM |
| Contacts | Signed By | Insert | New Registration | | Barbara, Daniel L
Chief Executive Officer
Ajo Community Health Center
5203875651-3007 | 4/2/2024 8:28 AM |
| Details | 340B ID | Update | New Registration | | CH09265C | 4/2/2024 8:28 AM |
| Dates | Participating Approval Date | Update | New Registration | | 4/2/2024 8:28:00 AM | 4/2/2024 8:28 AM |
| Details | State | Update | New Registration | Pending | Approved | 4/2/2024 8:28 AM |
| Dates | Signed By Date | Update | New Registration | | 4/1/2024 1:26:32 PM | 4/2/2024 8:28 AM |
| Dates | Start Date | Update | New Registration | | 7/1/2024 12:00:00 AM | 4/2/2024 8:28 AM |
| Addresses | Main Address | Insert | New Registration | |
13060 S Sunland Gin Rd
Arizona City, AZ 85123-8448 | 4/1/2024 11:32 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | New Registration | | False | 4/1/2024 11:32 AM |
| Medicaid Billing | Medicaid: Number | Insert | New Registration | | 486492 145677 | 4/1/2024 11:32 AM |
| Medicaid Billing | Medicaid: State | Insert | New Registration | | AZ | 4/1/2024 11:32 AM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1164751285 | 4/1/2024 11:32 AM |
| Medicaid Billing | NPI: State | Insert | New Registration | | AZ | 4/1/2024 11:32 AM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1487399937 | 4/1/2024 11:32 AM |
| Medicaid Billing | NPI: State | Insert | New Registration | | AZ | 4/1/2024 11:32 AM |
| Contacts | Primary Contact | Insert | New Registration | | Hatchard, Jared
Pharmacy Director
Ajo Community Health Center
5203875651-4249 | 4/1/2024 11:32 AM |
| Contacts | Authorizing Official | Insert | New Registration | | Barbara, Daniel L
Chief Executive Officer
Ajo Community Health Center
5203875651-3007 | 4/1/2024 11:32 AM |
| Details | Assistance Received From Date | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Details | Assistance Received To Date | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Details | Last Recertification Date | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Details | Grant Number | Insert | New Registration | | H80CS00753 | 4/1/2024 11:32 AM |
| Details | 340B ID | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Details | Medicare Provider Number | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Details | Entity Name | Insert | New Registration | | AJO COMMUNITY HEALTH CENTER | 4/1/2024 11:32 AM |
| Details | NOFO Number | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Details | Program Code | Insert | New Registration | | CH | 4/1/2024 11:32 AM |
| Details | Entity Subname | Insert | New Registration | | Desert Senita Community Health Center Arizona City | 4/1/2024 11:32 AM |
| Dates | Participating Approval Date | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Details | State | Insert | New Registration | | Pending | 4/1/2024 11:32 AM |
| Dates | Registration Date | Insert | New Registration | | 4/1/2024 11:32:16 AM | 4/1/2024 11:32 AM |
| Dates | Signed By Date | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Dates | Start Date | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Terminations | Termination Comments | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Terminations | Termination Date | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 4/1/2024 11:32 AM |
| Terminations | Termination Reason | Insert | New Registration | | | 4/1/2024 11:32 AM |