Covered Entity Details

DSH050485F Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center (Active) - information as of 5/27/2025 2:36:36 PM

Main Details

Name

Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center

Subdivision Name

PET Scanning - PET Scanning

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050485F

Medicare Provider Number

050485

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/2/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/8/2024

Last Recertification Date

Contacts

Authorizing Official

MemorialCare Long Beach Medical Center
Frank Beirne, Chief Executive Officer
(562) 933-1111

Primary Contact

Long Beach Medical Center & Millier Children's and Women's Hospital
Jennifer T Chang, Executive Director, Pharmacy Services
(562) 933-0282

Addresses

Street Address

2888 Long Beach Blvd
110
Long Beach, CA 90806

Billing Address

Long Beach Memorial Medical Center
17360 Brookhurst Street
Fountain Valley, CA 92708

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	0247625,HSP40485G,HSC40485G	1972514503,1891890158,1962442012,1053653782

Shipping Addresses

Same as Street Address

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
DSH050485A	Child	DSH	Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center	LBM Multi-Specialty Center - Adult specialty clinic	2865 Atlantic Ave, Suite 104	Long Beach	CA	Active
DSH050485B	Child	DSH	Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center	CNC Ambulatory Infusion Program	2810 Long Beach Blvd	Long Beach	CA	Active
DSH050485C	Child	DSH	Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center	TCI Specialty Center (3rd Floor)	2810 Long Beach Blvd	Long Beach	CA	Active
DSH050485D	Child	DSH	Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center	LBMC Multi-Specialty Center - Cardiology	2865 Atlantic Ave, Suite 210	Long Beach	CA	Terminated
DSH050485E	Child	DSH	Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center	TCI SPECIALTY CLINIC - 2ND FLOOR	2810 Long Beach Blvd	Long Beach	CA	Active
DSH050485F	Child	DSH	Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center	PET Scanning - PET Scanning	2888 Long Beach Blvd	Long Beach	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Kent, Blair Chief Executive Officer Long Beach Medical Center 5629331111	Beirne, Frank Chief Executive Officer MemorialCare Long Beach Medical Center 5629331111	5/9/2025 6:46 AM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Authorizing Official	Update	Change Request	Pilgrim, Patti Chief Financial Officer MemorialCare Long beach medical Center/Miller children's & Women's Hospital 5629331905	Kent, Blair Chief Executive Officer Long Beach Medical Center 5629331111	12/12/2024 1:37 PM
Contacts	Signed By	Insert	New Registration		Pilgrim, Patti Chief Financial Officer MemorialCare Long beach medical Center/Miller children's & Women's Hospital 5629331905	10/8/2024 7:58 AM
Details	340B ID	Update	New Registration		DSH050485F	10/8/2024 7:58 AM
Details	Entity Name	Update	New Registration	MEMORIALCARE LONG BEACH MED CTR	Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center	10/8/2024 7:58 AM
Details	Entity Subname	Update	New Registration	PET Scanning	PET Scanning - PET Scanning	10/8/2024 7:58 AM
Dates	Participating Approval Date	Update	New Registration		10/8/2024 7:58:59 AM	10/8/2024 7:58 AM
Details	State	Update	New Registration	Pending	Approved	10/8/2024 7:58 AM
Dates	Signed By Date	Update	New Registration		10/7/2024 10:57:02 AM	10/8/2024 7:58 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/8/2024 7:58 AM
Addresses	Main Address	Insert	New Registration		2888 Long Beach Blvd 110 Long Beach, CA 90806	10/2/2024 4:52 PM
Addresses	Billing Address	Insert	New Registration		Long Beach Memorial Medical Center 17360 Brookhurst Street Fountain Valley, CA 92708	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0247625	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HSP40485G	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HSC40485G	10/2/2024 4:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	10/2/2024 4:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972514503	10/2/2024 4:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/2/2024 4:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891890158	10/2/2024 4:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/2/2024 4:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1962442012	10/2/2024 4:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/2/2024 4:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1053653782	10/2/2024 4:52 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	10/2/2024 4:52 PM
Contacts	Primary Contact	Insert	New Registration		Chang, Jennifer T Executive Director, Pharmacy Services Long Beach Medical Center & Millier Children's and Women's Hospital 5629330282	10/2/2024 4:52 PM
Contacts	Authorizing Official	Insert	New Registration		Pilgrim, Patti Chief Financial Officer MemorialCare Long beach medical Center/Miller children's & Women's Hospital 5629331905	10/2/2024 4:52 PM
Details	Assistance Received From Date	Insert	New Registration			10/2/2024 4:52 PM
Details	Assistance Received To Date	Insert	New Registration			10/2/2024 4:52 PM
Details	Last Recertification Date	Insert	New Registration			10/2/2024 4:52 PM
Details	Grant Number	Insert	New Registration			10/2/2024 4:52 PM
Details	340B ID	Insert	New Registration			10/2/2024 4:52 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/2/2024 4:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/2/2024 4:52 PM
Details	Medicare Provider Number	Insert	New Registration		050485	10/2/2024 4:52 PM
Details	Entity Name	Insert	New Registration		MEMORIALCARE LONG BEACH MED CTR	10/2/2024 4:52 PM
Details	NOFO Number	Insert	New Registration			10/2/2024 4:52 PM
Details	Program Code	Insert	New Registration		DSH	10/2/2024 4:52 PM
Details	Entity Subname	Insert	New Registration		PET Scanning	10/2/2024 4:52 PM
Dates	Participating Approval Date	Insert	New Registration			10/2/2024 4:52 PM
Details	State	Insert	New Registration		Pending	10/2/2024 4:52 PM
Dates	Registration Date	Insert	New Registration		10/2/2024 4:52:21 PM	10/2/2024 4:52 PM
Dates	Signed By Date	Insert	New Registration			10/2/2024 4:52 PM
Dates	Start Date	Insert	New Registration			10/2/2024 4:52 PM
Terminations	Termination Comments	Insert	New Registration			10/2/2024 4:52 PM
Terminations	Termination Date	Insert	New Registration			10/2/2024 4:52 PM
Terminations	Termination Effective Date	Insert	New Registration			10/2/2024 4:52 PM
Terminations	Termination Reason	Insert	New Registration			10/2/2024 4:52 PM