| Details | Last Recertification Date | Update | Recertification | 1/29/2024 3:25:32 PM | 2/13/2025 11:35:14 AM | 2/13/2025 11:35 AM |
| Contacts | Authorizing Official | Update | AO Change Request | CORIA, EFRAIN
CHIEF OPERATIONS OFFICER
Gardner Family Health Network, Inc.
4082002291 | Clark, Corina B
Chief Operational Officer
Gardner Family Health Network
6693060060 | 2/11/2025 6:33 AM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2023 6:48:14 PM | 1/29/2024 3:25:32 PM | 1/29/2024 3:25 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2022 2:16:40 PM | 1/30/2023 6:48:14 PM | 1/30/2023 6:48 PM |
| Contacts | Primary Contact | Update | PC Change Request | Tong, Helen
Director of Pharmacy
Gardner Family Health Network, Inc.
4089182613 | Ha, Thuy-Trang Nu
Pharmacy Director
Gardner Family Health Network
4089182613 | 12/29/2022 9:39 AM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2021 6:27:56 PM | 1/31/2022 2:16:40 PM | 1/31/2022 2:16 PM |
| Details | Last Recertification Date | Update | Recertification | 1/27/2020 3:51:19 PM | 2/1/2021 6:27:56 PM | 2/1/2021 6:27 PM |
| Medicaid Billing | NPI: State | Update | Change Request | | CA | 1/27/2021 7:37 PM |
| Medicaid Billing | NPI: State | Update | Change Request | | CA | 1/27/2021 7:37 PM |
| Medicaid Billing | NPI: State | Update | Change Request | | CA | 1/27/2021 7:37 PM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2019 6:00:10 PM | 1/27/2020 3:51:19 PM | 1/27/2020 3:51 PM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2018 2:35:18 PM | 1/29/2019 6:00:10 PM | 1/29/2019 6:00 PM |
| Details | Last Recertification Date | Update | Recertification | 1/26/2017 12:00:00 AM | 2/7/2018 2:35:18 PM | 2/7/2018 2:35 PM |
| Contacts | Authorizing Official | Update | | CORIA, EFRAIN
CHIEF OPERATIONS OFFICER
4082002291 | CORIA, EFRAIN
CHIEF OPERATIONS OFFICER
Gardner Family Health Network, Inc.
4082002291 | 1/29/2018 1:00 PM |
| Contacts | Primary Contact | Update | | Tong, Helen
Director of Pharmacy
4089182613 | Tong, Helen
Director of Pharmacy
Gardner Family Health Network, Inc.
4089182613 | 9/22/2017 3:08 PM |
| Addresses | Main Address | Insert | | |
7526 Monterey St
Gilroy, CA 95020-5826 | 1/26/2017 3:11 PM |
| Contacts | Primary Contact | Insert | | | Tong, Helen
Director of Pharmacy
4089182613 | 1/26/2017 3:11 PM |
| Contacts | Authorizing Official | Insert | | | CORIA, EFRAIN
CHIEF OPERATIONS OFFICER
4082002291 | 1/26/2017 3:11 PM |
| Details | Last Recertification Date | Update | | 2/22/2016 12:00:00 AM | 1/26/2017 12:00:00 AM | 1/26/2017 3:11 PM |
| Addresses | Billing Address | Insert | | | GARDNER FAMILY HEALTH NETWORK
1621 GOLD ST PO BOX 1240
ALVISO, CA 95002 | 1/18/2017 8:48 AM |
| Addresses | Shipping Address | Insert | | | GARDNER FAMILY HEALTH NETWORK INC
ST JAMES HEALTH CENTER PHARMACY
55 E JULIAN ST
SAN JOSE, CA 95112 | 1/18/2017 8:48 AM |
| Addresses | Shipping Address | Insert | | | GARDNER FAMILY HEALTH NETWORK INC
GARDNER SOUTH COUNTY HEALTH CENTER PHARMACY
7526 MONTEREY ST
GILROY, CA 95020 | 1/18/2017 8:48 AM |
| Addresses | Shipping Address | Insert | | | GARDNER FAMILY HEALTH NETWORK INC
GARDNER SOUTH COUNTY HEALTH CENTER
7526 MONTEREY ST
GILROY, CA 95020-5826 | 1/18/2017 8:48 AM |
| Details | Last Recertification Date | Update | | 3/4/2015 12:00:00 AM | 2/22/2016 12:00:00 AM | 2/22/2016 1:57 PM |
| Details | Last Recertification Date | Update | | 2/10/2014 12:00:00 AM | 3/4/2015 12:00:00 AM | 3/4/2015 12:15 PM |
| Details | Entity Name | Update | | GARDNER FAMILY HEALTH NETWORK, INC | Gardner Family Health Network, Inc. | 3/31/2014 4:25 PM |
| Details | Entity Subname | Update | | GARDNER SOUTH COUNTY HEALTH CENTER | GARDNER SOUTH COUNTY HEALTH CTR | 3/31/2014 4:25 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 2/10/2014 12:00:00 AM | 2/10/2014 5:50 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 3/1/2013 12:20 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1144358748 | 11/30/2012 8:35 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1821239112 | 11/30/2012 8:35 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1952479602 | 11/30/2012 8:35 AM |
| Details | Last Recertification Date | Insert | | | | 6/8/2007 2:39 PM |
| Details | Grant Number | Insert | | | H80CS00359 | 6/8/2007 2:39 PM |
| Details | 340B ID | Insert | | | CH09021P | 6/8/2007 2:39 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 6/8/2007 2:39 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 6/8/2007 2:39 PM |
| Details | Medicare Provider Number | Insert | | | | 6/8/2007 2:39 PM |
| Details | Entity Name | Insert | | | GARDNER FAMILY HEALTH NETWORK, INC | 6/8/2007 2:39 PM |
| Details | Program Code | Insert | | | CH | 6/8/2007 2:39 PM |
| Details | Entity Subname | Insert | | | GARDNER SOUTH COUNTY HEALTH CENTER | 6/8/2007 2:39 PM |
| Dates | Participating Approval Date | Insert | | | 3/8/2007 12:00:00 AM | 6/8/2007 2:39 PM |
| Details | State | Insert | | | Active | 6/8/2007 2:39 PM |
| Dates | Registration Date | Insert | | | 3/7/2007 12:00:00 AM | 6/8/2007 2:39 PM |
| Dates | Signed By Date | Insert | | | 5/31/2006 12:00:00 AM | 6/8/2007 2:39 PM |
| Dates | Start Date | Insert | | | 4/1/2007 12:00:00 AM | 6/8/2007 2:39 PM |
| Terminations | Termination Comments | Insert | | | | 6/8/2007 2:39 PM |
| Terminations | Termination Date | Insert | | | | 6/8/2007 2:39 PM |
| Terminations | Termination Effective Date | Insert | | | | 6/8/2007 2:39 PM |
| Terminations | Termination Reason | Insert | | | | 6/8/2007 2:39 PM |