Covered Entity Details

DSH050115 PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido) (Active) - information as of 6/21/2025 10:43:28 PM

Main Details

Name

PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050115

Medicare Provider Number

050115

Additional Details

Current Program Status

Active

Registration Date

3/2/2006

Participating Start Date

4/1/2006

Participating Approval Date

3/2/2006

Last Recertification Date

9/10/2024

Contacts

Authorizing Official

Palomar Health
Diane Lynette Hansen, President & CEO
(760) 740-6395

Primary Contact

Palomar Health
Dondreia Gelios, District Director Pharmacy Services
(442) 281-1358

Addresses

Street Address

2185 Citracado Parkway
Escondido, CA 92029

Billing Address

Palomar Health
120 Craven Road
San Marcos, CA 92078

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		1457321317,1275884736,1700239779,1205806676
AZ		1275884736,1457321317,1205806676,1700239779
CO		1275884736,1457321317,1205806676,1700239779

Shipping Addresses

Shipping Address 1

Palomar Medical Center Escondido
2185 Citracado Parkway
Escondido, CA 92029

Shipping Address 2

Palomar Medical Center Outpatient
2185 Citracado Parkway
Escondido, CA 92029

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	THRIFTY PAYLESS INC.	RITE AID #5628	315 WEST WASHINGTON AVENUE	ESCONDIDO	CA	92025	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS INC.	RITE AID #5637	12666 POWAY ROAD	POWAY	CA	92064	07/14/2017	10/01/2017	10/02/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5638	1670 MAIN STREET	RAMONA	CA	92065	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5629	1825 SOUTH CENTRE CITY PKWY.	ESCONDIDO	CA	92025	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5634	1201 SOUTH COAST HIGHWAY	OCEANSIDE	CA	92054	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5662	11845 CARMEL MOUNTAIN RD.	SAN DIEGO	CA	92128	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5631	1331 SOUTH MISSION ROAD	FALLBROOK	CA	92028	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5666	3515 DELMAR HEIGHTS ROAD	SAN DIEGO	CA	92130	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5621	955 TAMARACK AVENUE	CARLSBAD	CA	92008	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5642	1363 EAST VISTA WAY	VISTA	CA	92084	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5665	13167 BLACK MOUNTAIN ROAD	SAN DIEGO	CA	92129	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5622	7100 AVENIDA ENCINAS	CARLSBAD	CA	92011	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5620	661 SWEETWATER ROAD	SPRING VALLEY	CA	91977	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5652	3650 ADAMS AVENUE	SAN DIEGO	CA	92116	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5646	1735 EUCLID AVENUE	SAN DIEGO	CA	92105	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5635	3813 PLAZA DRIVE	OCEANSIDE	CA	92056	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5627	439 SANTA FE DRIVE 439 SANTA FE DRIVE	ENCINITAS	CA	92024	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5644	535 ROBINSON AVENUE	SAN DIEGO	CA	92103	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5613	4348 BONITA ROAD	BONITA	CA	91902	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5656	8694 LAKE MURRAY BOULEVARD	SAN DIEGO	CA	92119	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5653	5270 BALBOA AVENUE	SAN DIEGO	CA	92117	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5649	6939 LINDA VISTA ROAD	SAN DIEGO	CA	92111	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6481	32450 CLINTON KEITH ROAD	WILDOMAR	CA	92595	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5668	1854 CORONADO AVENUE	SAN DIEGO	CA	92154	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5632	9532 WINTER GARDENS BLVD.	LAKESIDE	CA	92040	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5647	4840 NIAGARA AVENUE	SAN DIEGO	CA	92107	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5469	31797 HIGHWAY 79 SOUTH	TEMECULA	CA	92592	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5623	2516 JAMACHA ROAD	EL CAJON	CA	92019	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6711	13460 HIGHLANDS PL	SAN DIEGO	CA	92130-2401	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5657	6505 MISSION GORGE ROAD	SAN DIEGO	CA	92120	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6225	1665 ALPINE BOULEVARD	ALPINE	CA	91901	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5658	4077 GOVERNOR DRIVE	SAN DIEGO	CA	92122	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5660	10631 TIERRASANTA BOULEVARD	SAN DIEGO	CA	92124	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5654	3081-B CLAIREMONT DRIVE	SAN DIEGO	CA	92117	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6438	39782 WINCHESTER ROAD	TEMECULA	CA	92591	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5651	6405 EL CAJON BOULEVARD	SAN DIEGO	CA	92115	07/14/2017	10/01/2017	12/14/2017	01/16/2018
Contract Detail	WALGREEN CO	DBA: WALGREENS #09433	3752 MISSION AVE	OCEANSIDE	CA	92058	12/17/2012	01/01/2013	06/12/2015	11/04/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05455	111 W WASHINGTON AVE	ESCONDIDO	CA	92025	12/17/2012	01/01/2013	06/12/2015	11/04/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05456	1510 N SANTA FE AVE	VISTA	CA	92083	12/17/2012	01/01/2013	06/12/2015	11/04/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05700	1574 E VALLEY PKWY	ESCONDIDO	CA	92027	12/17/2012	01/01/2013	06/12/2015	11/04/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06222	802 S SANTA FE AVE	VISTA	CA	92084-6107	12/17/2012	01/01/2013	06/12/2015	11/04/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09389	310 SYCAMORE AVENUE	VISTA	CA	92083-7702	12/17/2012	01/01/2013	06/12/2015	11/04/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10142	460 W FELICITA AVENUE	ESCONDIDO	CA	92025-6518	12/17/2012	01/01/2013	06/12/2015	11/04/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12421	13390 POWAY RD	POWAY	CA	92064	12/17/2012	01/01/2013	06/12/2015	11/04/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050115B	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Expresscare- San Elijo Hills (San Marcos)	1571 San Elijo Rd	San Marcos	CA	Terminated
DSH050115C	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Expresscare- Temecula	30530 Rancho California Rd	Temecula	CA	Terminated
DSH050115D	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Expresscare- Escondido	1509 East Valley Parkway	Escondido	CA	Terminated
DSH050115E	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	PHDC Operating Room/ Surgical Platform	555 E. Valley Parkway	Escondido	CA	Terminated
DSH050115F	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Emergency Room	555 E. Valley Parkway	Escondido	CA	Terminated
DSH050115G	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Chemotherapy (Infusion Center)	2125 Citracado Pkwy	Escondido	CA	Active
DSH050115H	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Wound Care	2130 Citracado Parkway Suite 110A	San Escondido	CA	Active
DSH050115J	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Downtown Campus / Behavioral Health Services	555 E. Valley Parkway	Escondido	CA	Terminated
DSH050115K	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Outpatient Behavioral Health	125 Vallecitos De Oro, Suite A	San Marcos	CA	Terminated
DSH050115L	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Downtown Campus / PHDC Radiology Diagnostic	555 E. Valley Parkway	Escondido	CA	Terminated
DSH050115M	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Home Health	120 Craven Road	San Marcos	CA	Active
DSH050115N	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	PMC Escondido - Crisis Stabilization Unit	2185 Citracado Parkway	Escondido	CA	Active
DSH050115P	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Radiation Oncology - Radiation Oncology	2125 Citracado Parkway	Escondido	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Delete	Recertification	1285752063 (CA)		9/10/2024 7:29 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1285752063 (AZ)		9/10/2024 7:29 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1285752063 (CO)		9/10/2024 7:29 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700239779	9/10/2024 7:29 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/10/2024 7:29 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1205806676	9/10/2024 7:29 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/10/2024 7:29 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1205806676	9/10/2024 7:29 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/10/2024 7:29 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700239779	9/10/2024 7:29 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/10/2024 7:29 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1205806676	9/10/2024 7:29 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/10/2024 7:29 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1700239779	9/10/2024 7:29 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/10/2024 7:29 AM
Details	Last Recertification Date	Update	Recertification	9/7/2023 2:40:12 PM	9/10/2024 7:29:55 AM	9/10/2024 7:29 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 7:35:27 PM	9/7/2023 2:40:12 PM	9/7/2023 2:40 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	050115 (CA)		9/7/2022 7:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1285752063	9/7/2022 7:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/7/2022 7:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1275884736	9/7/2022 7:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/7/2022 7:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457321317	9/7/2022 7:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/7/2022 7:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1285752063	9/7/2022 7:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/7/2022 7:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1275884736	9/7/2022 7:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/7/2022 7:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457321317	9/7/2022 7:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/7/2022 7:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1285752063	9/7/2022 7:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/7/2022 7:35 PM
Details	Last Recertification Date	Update	Recertification	9/3/2021 10:17:51 AM	9/7/2022 7:35:27 PM	9/7/2022 7:35 PM
Contacts	Authorizing Official	Update	Change Request	Bogert, Michael John Chief Financial Officer Palomar Health 7607406385	Hansen, Diane Lynette President & CEO Palomar Health 7607406395	4/11/2022 2:26 PM
Addresses	Billing Address	Update	Recertification	Palomar Health 800 W. Valley Parkway, Suite #201 Escondido, CA 92025	Palomar Health 120 Craven Road San Marcos, CA 92078	9/3/2021 10:17 AM
Details	Last Recertification Date	Update	Recertification	8/19/2020 4:16:19 PM	9/3/2021 10:17:51 AM	9/3/2021 10:17 AM
Contacts	Primary Contact	Update	Change Request	Skeets, Zephyr Manager Pharmacy Business Operations Palomar Health 4422811385	Gelios, Dondreia District Director Pharmacy Services Palomar Health 4422811358	7/28/2021 8:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1275884736	4/13/2021 3:47 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/13/2021 3:47 PM
Contacts	Authorizing Official	Update	Change Request	King, Hubert U. Chief Financial Officer Palomar Health 7607406385	Bogert, Michael John Chief Financial Officer Palomar Health 7607406385	1/22/2021 11:02 AM
Contacts	Authorizing Official	Update	AO Change Request	Bohorquez, Carlos A. Chief FInancial Officer Palomar Health 7607406385	King, Hubert U. Chief Financial Officer Palomar Health 7607406385	8/31/2020 2:51 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457321317	8/19/2020 4:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/19/2020 4:16 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1457321317 ( )		8/19/2020 4:16 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 7:34:32 AM	8/19/2020 4:16:19 PM	8/19/2020 4:16 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 1:19:49 PM	8/27/2019 7:34:32 AM	8/27/2019 7:34 AM
Contacts	Primary Contact	Update	Profile Change Request	Skeets, Zephyr Manager Pharmacy Business Operations Palomar Health 7607392849	Skeets, Zephyr Manager Pharmacy Business Operations Palomar Health 4422811385	8/22/2019 1:00 PM
Contacts	Authorizing Official	Update	AO Change Request	King, Hubert U. Chief Financial Officer Palomar Health 7607406385	Bohorquez, Carlos A. Chief FInancial Officer Palomar Health 7607406385	3/20/2019 8:54 AM
Addresses	Shipping Address	Delete	Change Request	Palomar Medical Center Outpatient 2185 Citracado Pkwy California, CA 92029		11/19/2018 9:37 AM
Addresses	Shipping Address	Insert	Change Request		Palomar Medical Center Outpatient 2185 Citracado Parkway Escondido, CA 92029	11/19/2018 9:37 AM
Addresses	Shipping Address	Insert	Change Request		Palomar Medical Center Outpatient 2185 Citracado Pkwy California, CA 92029	10/17/2018 1:05 PM
Addresses	Shipping Address	Insert	Change Request		Palomar Medical Center Escondido 2185 Citracado Parkway Escondido, CA 92029	10/17/2018 1:05 PM
Details	Last Recertification Date	Update	Recertification	11/30/2017 2:37:21 PM	8/30/2018 1:19:49 PM	8/30/2018 1:19 PM
Contacts	Authorizing Official	Update	Profile Change Request	King, Hubert U. Interim Chief Financial Officer Palomar Health 7607406385	King, Hubert U. Chief Financial Officer Palomar Health 7607406385	8/15/2018 6:27 PM
Contacts	Primary Contact	Update	Change Request	Lee, Jeremy District Director Pharmacy Services Palomar Health 7607393935	Skeets, Zephyr Manager Pharmacy Business Operations Palomar Health 7607392849	7/23/2018 12:57 PM
Contacts	Authorizing Official	Update	Change Request	Hansen, Diane Executive VP Finance Palomar Health 7607406385	King, Hubert U. Interim Chief Financial Officer Palomar Health 7607406385	1/11/2018 1:27 PM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	11/30/2017 2:37:21 PM	11/30/2017 2:37 PM
Contacts	Authorizing Official	Update		Hansen, Diane Executive VP Finance 7607406385	Hansen, Diane Executive VP Finance Palomar Health 7607406385	10/25/2017 12:00 PM
Contacts	Primary Contact	Update		Lee, Jeremy District Director Pharmacy Services 7607393935	Lee, Jeremy District Director Pharmacy Services Palomar Health 7607393935	9/29/2017 12:55 PM
Contacts	Primary Contact	Insert			Lee, Jeremy District Director Pharmacy Services 7607393935	8/1/2017 3:35 PM
Contacts	Authorizing Official	Insert			Hansen, Diane Executive VP Finance 7607406385	8/1/2017 3:35 PM
Addresses	Main Address	Insert			2185 Citracado Parkway Escondido, CA 92029	6/15/2017 10:44 AM
Addresses	Billing Address	Insert			Palomar Health 800 W. Valley Parkway, Suite #201 Escondido, CA 92025	6/15/2017 10:44 AM
Details	Entity Name	Update		PALOMAR MEDICAL CENTER	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	6/15/2017 10:43 AM
Details	Last Recertification Date	Update		9/4/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 1:40 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	9/4/2015 11:35 AM
Medicaid Billing	Medicaid: Number	Update		PHB349510	050115	9/4/2015 11:35 AM
Details	Last Recertification Date	Update		8/29/2014 12:00:00 AM	9/4/2015 12:00:00 AM	9/4/2015 11:35 AM
Details	Last Recertification Date	Update		9/6/2013 12:00:00 AM	8/29/2014 12:00:00 AM	8/29/2014 7:31 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/6/2013 12:00:00 AM	9/6/2013 6:47 AM
Medicaid Billing	NPI: Number	Insert			1457321317	5/15/2012 7:14 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/15/2012 7:14 AM
Details	Last Recertification Date	Insert				3/2/2006 1:27 PM
Details	Grant Number	Insert				3/2/2006 1:27 PM
Details	340B ID	Insert			DSH050115	3/2/2006 1:27 PM
Details	Is Authorizing Official EHB Data	Insert				3/2/2006 1:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert				3/2/2006 1:27 PM
Details	Medicare Provider Number	Insert			050115	3/2/2006 1:27 PM
Details	Entity Name	Insert			PALOMAR MEDICAL CENTER	3/2/2006 1:27 PM
Details	Program Code	Insert			DSH	3/2/2006 1:27 PM
Details	Entity Subname	Insert				3/2/2006 1:27 PM
Dates	Participating Approval Date	Insert			3/2/2006 12:00:00 AM	3/2/2006 1:27 PM
Details	State	Insert			Active	3/2/2006 1:27 PM
Dates	Registration Date	Insert			3/2/2006 12:00:00 AM	3/2/2006 1:27 PM
Dates	Signed By Date	Insert			3/1/2006 12:00:00 AM	3/2/2006 1:27 PM
Dates	Start Date	Insert			4/1/2006 12:00:00 AM	3/2/2006 1:27 PM
Terminations	Termination Comments	Insert				3/2/2006 1:27 PM
Terminations	Termination Date	Insert				3/2/2006 1:27 PM
Terminations	Termination Effective Date	Insert				3/2/2006 1:27 PM
Terminations	Termination Reason	Insert				3/2/2006 1:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	3/2/2006 7:44 AM
Medicaid Billing	Medicaid: Number	Insert			PHB349510	3/2/2006 7:44 AM
Medicaid Billing	Medicaid: State	Insert			CA	3/2/2006 7:44 AM