Covered Entity Details

DSH290007AT UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA (Approved) - information as of 5/6/2025 11:03:40 PM

Main Details

Name

UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA

Subdivision Name

PC @ The Medical District - Primary Care

Type

Disproportionate Share Hospital

Rural

340B ID

DSH290007AT

Medicare Provider Number

290007

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/15/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/30/2025

Last Recertification Date

Contacts

Authorizing Official

University Medical Center of Southern Nevada
Mason Van Houweling, CEO
(702) 383-3862

Primary Contact

University Medical Center of Southern Nevada
Jamie King, Director, Pharmaceutical Services
(702) 383-3791

Addresses

Street Address

1524 Pinto Lane
2nd Floor
Las Vegas, NV 89106

Billing Address

University Medical Center of Southern Nevada
1800 W. Charleston Blvd.
Las Vegas, NV 89102

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
NV	1002877,1104538966,1202877,1376105478,1467014571,1538721642,1548393127,1568024669,1609900521,1649832759,1710549829,1760517635,1881727360,1891357901,1891820775,1942335823,1982662912,1992367007	1104538966,1376105478,1467014571,1538721642,1548393127,1568024669,1609900521,1649832759,1710549829,1760517635,1881727360,1891357901,1891820775,1942335823,1982662912,1992367007
CA	1548393127	1104538966,1376105478,1467014571,1538721642,1548393127,1568024669,1609900521,1649832759,1710549829,1760517635,1881727360,1891357901,1891820775,1942335823,1982662912,1992367007
UT	1548393127	1104538966,1376105478,1467014571,1538721642,1548393127,1568024669,1609900521,1649832759,1710549829,1760517635,1881727360,1891357901,1891820775,1942335823,1982662912,1992367007
ID	1548393127	1104538966,1376105478,1467014571,1538721642,1548393127,1568024669,1609900521,1649832759,1710549829,1760517635,1881727360,1891357901,1891820775,1942335823,1982662912,1992367007
AZ	20917	1104538966,1376105478,1467014571,1538721642,1548393127,1568024669,1609900521,1649832759,1710549829,1760517635,1881727360,1891357901,1891820775,1942335823,1982662912,1992367007
OR	36624	1104538966,1376105478,1467014571,1538721642,1548393127,1568024669,1609900521,1649832759,1710549829,1760517635,1881727360,1891357901,1891820775,1942335823,1982662912,1992367007

Shipping Addresses

Shipping Address 1

University Medical Center of Southern Nevada
1800 W. Charleston Blvd.
Las Vegas, NV 89102

Shipping Address 2

Safecor
4060 Business Park Dr.
Suite B
Columbus, OH 43204

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
DSH290007AA	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	PRIMARY CARE: SPRING VALLEY	4180 S Rainbow Blvd.	Las Vegas	NV	Active
DSH290007AB	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	PRIMARY CARE: SUNSET	525 Marks Street	Henderson	NV	Active
DSH290007AC	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	PRIMARY CARE: SOUTHERN HIGHLANDS	11860 Southern Highlands Parkway	Las Vegas	NV	Active
DSH290007AD	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	EMERGENCY: PEDIATRICS	800 Hope Place, 3rd floor	Las Vegas	NV	Active
DSH290007AE	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	TRAUMA CENTER	800 Hope Place, 1st floor	Las Vegas	NV	Active
DSH290007AF	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	CLINIC:PEDIATRICS OUTPATIENT	800 Hope Place, 3rd floor	Las Vegas	NV	Active
DSH290007AG	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: CENTENNIAL	5785 Centennial Center Blvd.	LAS VEGAS	NV	Active
DSH290007AH	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	PRIMARY CARE: CENTENNIAL	5785 Centennial Center Blvd.	Las Vegas	NV	Active
DSH290007AJ	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: BLUE DIAMOND	4760 Blue Diamond Rd.	LAS VEGAS	NV	Active
DSH290007AK	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	UNIVERSITY MEDICAL CENTER - EXPRESS CARE	5757 WAYNE NEWTON BLVD	LAS VEGAS	NV	Active
DSH290007AL	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	UMC WELLNESS CENTER - PEDIATRIC INFECTIOUS DISEASE HOD CLINIC	701 SHADOW LN	LAS VEGAS	NV	Active
DSH290007AM	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	UMC WELLNESS CENTER - PRIMARY CARE: WELLNESS	701 SHADOW LN	LAS VEGAS	NV	Active
DSH290007AN	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	WELLNESS CENTER - INFECTIOUS DISEASE OUTPATIENT	701 SHADOW LANE	LAS VEGAS	NV	Active
DSH290007AP	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	Orthopedic Clinic - Orthopedics	2231 W. Charleston Blvd.	Las Vegas	NV	Active
DSH290007AQ	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	Aliante Primary Care - Primary Care	5860 Losee Road	North Las Vegas	NV	Active
DSH290007AR	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	OP Infusion Clinic - Outpatient Infusions	701 Shadow Lane	Las Vegas	NV	Active
DSH290007AS	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	Aliante Quick Care - Quick Care	5860 Losee Road	North Las Vegas	NV	Active
DSH290007AT	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	PC @ The Medical District - Primary Care	1524 Pinto Lane	Las Vegas	NV	Approved
DSH290007AU	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	Ortho Clinic @ Rancho - Orthopedics	4231 N. Rancho Dr.	Las Vegas	NV	Approved
DSH290007K	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: PECCOLE	9320 W. Sahara Ave.	Las Vegas	NV	Active
DSH290007L	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: ENTERPRISE	1700 Wheeler Peak Dr.	Las Vegas	NV	Active
DSH290007M	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: SUNSET	525 Marks St.	Henderson	NV	Active
DSH290007N	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	CLINIC: POST TRANSPLANT	901 Rancho Lane	Las Vegas	NV	Active
DSH290007P	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	CLINIC: HIV WELLNESS CENTER	701 Shadow Lane	Las Vegas	NV	Active
DSH290007S	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: SUMMERLIN	2031 N. Buffalo Dr.	Las Vegas	NV	Active
DSH290007T	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: SPRING VALLEY	4180 S. Rainbow Blvd.	Las Vegas	NV	Active
DSH290007U	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: RANCHO/CRAIG	4231 N. Rancho Dr.	Las Vegas	NV	Active
DSH290007V	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	QUICK CARE: NELLIS	61 N. Nellis Blvd.	Las Vegas	NV	Active
DSH290007W	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	PRIMARY CARE: NELLIS	63 N Nellis Blvd.	Las Vegas	NV	Active
DSH290007X	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	PRIMARY CARE: PECCOLE	9320 W Sahara Ave.	Las Vegas	NV	Active
DSH290007Y	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	PRIMARY CARE: SUMMERLIN	2031 N Buffalo Drive	Las Vegas	NV	Active
DSH290007Z	Child	DSH	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	UMC PRIMARY CARE - RANCHO/CRAIG	4233 N RANCHO DRIVE	LAS VEGAS	NV	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Van Houweling, Mason CEO University Medical Center of Southern Nevada 7023833862	4/30/2025 3:31 PM
Details	340B ID	Update	New Registration		DSH290007AT	4/30/2025 3:31 PM
Details	Entity Name	Update	New Registration	UNIVERSITY MEDICAL CENTER	UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA	4/30/2025 3:31 PM
Details	Entity Subname	Update	New Registration	PC @ The Medical District	PC @ The Medical District - Primary Care	4/30/2025 3:31 PM
Dates	Participating Approval Date	Update	New Registration		4/30/2025 3:31:27 PM	4/30/2025 3:31 PM
Details	State	Update	New Registration	Pending	Approved	4/30/2025 3:31 PM
Dates	Signed By Date	Update	New Registration		4/15/2025 7:03:49 PM	4/30/2025 3:31 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/30/2025 3:31 PM
Addresses	Main Address	Insert	New Registration		1524 Pinto Lane 2nd Floor Las Vegas, NV 89106	4/15/2025 2:22 PM
Addresses	Billing Address	Insert	New Registration		University Medical Center of Southern Nevada 1800 W. Charleston Blvd. Las Vegas, NV 89102	4/15/2025 2:22 PM
Addresses	Shipping Address	Insert	New Registration		University Medical Center of Southern Nevada 1800 W. Charleston Blvd. Las Vegas, NV 89102	4/15/2025 2:22 PM
Addresses	Shipping Address	Insert	New Registration		Safecor 4060 Business Park Dr. Suite B Columbus, OH 43204	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1002877	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1104538966	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1202877	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1376105478	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1467014571	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1538721642	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1568024669	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1609900521	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1649832759	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1710549829	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1760517635	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1881727360	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1891357901	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1891820775	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1942335823	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1982662912	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1992367007	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		20917	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		36624	4/15/2025 2:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104538966	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376105478	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467014571	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538721642	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1568024669	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609900521	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649832759	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710549829	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760517635	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1881727360	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891357901	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891820775	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942335823	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982662912	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992367007	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104538966	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376105478	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467014571	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538721642	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1568024669	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609900521	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649832759	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710549829	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760517635	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1881727360	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891357901	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891820775	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942335823	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982662912	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992367007	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104538966	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376105478	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467014571	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538721642	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1568024669	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609900521	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649832759	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710549829	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760517635	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1881727360	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891357901	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891820775	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942335823	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982662912	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992367007	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104538966	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376105478	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467014571	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538721642	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1568024669	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609900521	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649832759	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710549829	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760517635	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1881727360	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891357901	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891820775	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942335823	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982662912	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992367007	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104538966	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376105478	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467014571	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538721642	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1568024669	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609900521	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649832759	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710549829	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760517635	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1881727360	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891357901	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891820775	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942335823	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982662912	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992367007	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1104538966	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1376105478	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467014571	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1538721642	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548393127	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1568024669	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609900521	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1649832759	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710549829	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760517635	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1881727360	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891357901	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891820775	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1942335823	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1982662912	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992367007	4/15/2025 2:22 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/15/2025 2:22 PM
Contacts	Primary Contact	Insert	New Registration		King, Jamie Director, Pharmaceutical Services University Medical Center of Southern Nevada 7023833791	4/15/2025 2:22 PM
Contacts	Authorizing Official	Insert	New Registration		Van Houweling, Mason CEO University Medical Center of Southern Nevada 7023833862	4/15/2025 2:22 PM
Details	Assistance Received From Date	Insert	New Registration			4/15/2025 2:22 PM
Details	Assistance Received To Date	Insert	New Registration			4/15/2025 2:22 PM
Details	Last Recertification Date	Insert	New Registration			4/15/2025 2:22 PM
Details	Grant Number	Insert	New Registration			4/15/2025 2:22 PM
Details	340B ID	Insert	New Registration			4/15/2025 2:22 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/15/2025 2:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/15/2025 2:22 PM
Details	Medicare Provider Number	Insert	New Registration		290007	4/15/2025 2:22 PM
Details	Entity Name	Insert	New Registration		UNIVERSITY MEDICAL CENTER	4/15/2025 2:22 PM
Details	NOFO Number	Insert	New Registration			4/15/2025 2:22 PM
Details	Program Code	Insert	New Registration		DSH	4/15/2025 2:22 PM
Details	Entity Subname	Insert	New Registration		PC @ The Medical District	4/15/2025 2:22 PM
Dates	Participating Approval Date	Insert	New Registration			4/15/2025 2:22 PM
Details	State	Insert	New Registration		Pending	4/15/2025 2:22 PM
Dates	Registration Date	Insert	New Registration		4/15/2025 2:22:22 PM	4/15/2025 2:22 PM
Dates	Signed By Date	Insert	New Registration			4/15/2025 2:22 PM
Dates	Start Date	Insert	New Registration			4/15/2025 2:22 PM
Terminations	Termination Comments	Insert	New Registration			4/15/2025 2:22 PM
Terminations	Termination Date	Insert	New Registration			4/15/2025 2:22 PM
Terminations	Termination Effective Date	Insert	New Registration			4/15/2025 2:22 PM
Terminations	Termination Reason	Insert	New Registration			4/15/2025 2:22 PM