Covered Entity Details

DSH050060 COMMUNITY REGIONAL MEDICAL CENTER (Active) - information as of 5/2/2025 10:34:04 PM

Main Details

Name

COMMUNITY REGIONAL MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050060

Medicare Provider Number

050060

Additional Details

Current Program Status

Active

Registration Date

3/12/2007

Participating Start Date

4/1/2007

Participating Approval Date

3/12/2007

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Community Medical Center
Tracy Kiritani, VP Hospital Financial Operations
(559) 324-4844

Primary Contact

Community Medical Center
Joel Weber, Director of Finance -Pharmacy and 340B
(559) 231-1504

Addresses

Street Address

2823 FRESNO STREET
FRESNO, CA 93721

Billing Address

COMMUNITY REGIONAL MEDICAL CENTER
P. O. BOX 1232
FRESNO, CA 93715-1231

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
12/17/08 UPDATED ADDR (WAS FRESNO & R STREET); 12/17/08 ADDED SHIP TO; 12/17/08 ADDED BILL TO; 4/1/07 UPDATED ADDR (WAS 2823 FRESNO ST., FRESNO, CA)	01/21/2010

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	PHB419240,HSP40060F	1104906569,1821179656,1497836613

Shipping Addresses

Shipping Address 1

Community Home Infusion
1630 E. Shaw Ave, Suite 172
Fresno, CA 93710

Shipping Address 2

CRMC Infusion Center - Clovis
729 N. Medical Center Drive, West.suite 213
Clovis, CA 93611

Shipping Address 3

Fresno Heart and Surgical Hospital
15 E. Audubon Drive
Fresno, CA 93720-1542

Shipping Address 4

COMMUNITY REGIONAL MEDICAL CENTER
2130 EAST ILLINOIS Avenue
FRESNO, CA 93701

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	COMMUNITY HOME INFUSION		1925 E DAKOTA AVE SUITE #211	FRESNO	CA	93726	04/08/2013	07/01/2013	08/03/2016	07/12/2017
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	3101 SILLECT AVENUE, SUITE 109	BAKERSFIELD	CA	93308-6348	04/10/2017	07/01/2017	08/01/2017	08/01/2017
Contract Detail	CORAM HEALTHCARE CORP OF SOUTHERN CALIFO	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	2710 MEDIA CENTER DRIVE, BLDG. #6, SUITE 150	LOS ANGELES	CA	90065	04/10/2017	07/01/2017	08/01/2017	08/01/2017
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	10/04/2016	01/01/2017	08/09/2017	08/09/2017
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	06/30/2017	07/01/2017	01/25/2018	01/29/2018
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 05422	5180 E. KINGS CANYON ROAD	FRESNO	CA	93727	10/21/2013	01/01/2014	01/21/2017	07/12/2017
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 06772	4987 N. FRESNO ST.	FRESNO	CA	93726	10/21/2013	01/01/2014	01/21/2017	07/12/2017
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 07553	3011 E SHIELDS AVE	FRESNO	CA	93726	10/21/2013	01/01/2014	01/21/2017	07/12/2017
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09129	1302 FULTON MALL	FRESNO	CA	93721	10/21/2013	01/01/2014	01/21/2017	07/12/2017
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09537	1325 W SHIELDS AVENUE	FRESNO	CA	93705	10/21/2013	01/01/2014	01/21/2017	07/12/2017
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/10/2017	07/01/2017	01/10/2018	01/11/2018
Contract Detail	UNIVERSITY MEDICAL CENTER PHARMACY	290 N WAYTE LN FL 1		FRESNO	CA	93701-2124	07/02/2020	10/01/2020		09/17/2024
Contract Detail	WAL-MART PHARMACY 10-1815	4080 W SHAW AVE		FRESNO	CA	93722	07/10/2014	10/01/2014	10/18/2016	07/12/2017
Contract Detail	WAL-MART PHARMACY 10-2001	5125 EAST KINGS CANYON		FRESNO	CA	93727	07/10/2014	10/01/2014	10/18/2016	07/12/2017
Contract Detail	WAL-MART PHARMACY 10-2277	323 WEST SHAW AVE		CLOVIS	CA	93612	07/10/2014	10/01/2014	10/18/2016	07/12/2017
Contract Detail	WAL-MART PHARMACY 10-2985	7065 NORTH INGRAM AVENUE		FRESNO (N)	CA	93650	07/10/2014	10/01/2014	10/18/2016	07/12/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #10243	2420 N BLACKSTONE AVE	FRESNO	CA	93703-1747	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO	DBA: WALGREENS #10335	2424 N BRAWLEY AVE	FRESNO	CA	93722	10/02/2015	01/01/2016	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02702	1344 W CLINTON AVE	FRESNO	CA	93705	10/21/2013	01/01/2014	06/27/2017	07/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06082	626 S CLOVIS AVE	FRESNO	CA	93727	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA WALGREENS #06386	4810 E CESAR CHAVEZ BLVD	FRESNO	CA	93727	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06387	1815 HERNDON AVE	CLOVIS	CA	93611	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06942	6010 N FIGARDEN DRIVE	FRESNO	CA	93722-6030	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07204	7015 N WEST AVE	FRESNO	CA	93711-0461	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07830	205 W SHAW AVENUE	CLOVIS	CA	93612-3602	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10334	1790 SHAW AVE	CLOVIS	CA	93611	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11877	4771 W ASHLAN AVE	FRESNO	CA	93722	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12282	2589 JENSEN AVE	SANGER	CA	93657	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12574	1219 N CEDAR AVE	FRESNO	CA	93703	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 13871	1016 W SHAW AVE	FRESNO	CA	93711	10/21/2013	01/01/2014	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 12707	4172 N. 1ST STREET	FRESNO	CA	93726	10/02/2015	01/01/2016	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05847	610 E NEES AVENUE	FRESNO	CA	93720	10/02/2015	01/01/2016	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07266	8975 N CHESTNUT AVE	FRESNO	CA	93720	10/02/2015	01/01/2016	05/19/2021	05/19/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12298	852 E MANNING AVE	REEDLEY	CA	93654	10/02/2015	01/01/2016	05/19/2021	05/19/2021
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	10/21/2013	01/01/2014	07/07/2015	07/12/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/04/2016	01/01/2017	01/25/2018	01/29/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	10/04/2016	01/01/2017	01/25/2018	01/29/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/04/2016	01/01/2017	01/25/2018	01/29/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/04/2016	01/01/2017	01/25/2018	01/29/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050060AA	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Ultrasound	15 E. Audubon Drive	Fresno	CA	Active
DSH050060AB	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Radiology Diagnostic	15 E. Audubon Drive	Fresno	CA	Active
DSH050060AC	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Anesthesiology	15 E. Audubon Drive	Fresno	CA	Active
DSH050060AD	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH PACU (Recovery)	15 E. Audubon Drive	Fresno	CA	Active
DSH050060AE	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Surgery	15 E. Audubon Drive	Fresno	CA	Active
DSH050060AF	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Short Stay Surgery	15 E. Audubon Drive	Fresno	CA	Active
DSH050060AG	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	COMMUNITY AMBULATORY INFUSION CENTE	729 N MEDICAL CENTER DR W	CLOVIS	CA	Active
DSH050060AH	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Clinic Prompt Care	290 N. Wayte Lane Ste 1800	Fresno	CA	Terminated
DSH050060AJ	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Home Program Dialysis	215 N. Fresno Street, ste. 150	Fresno	CA	Active
DSH050060AK	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Respiratory Services - Respiratory Therapy	15 E. Audubon Drive	Fresno	CA	Active
DSH050060AL	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Community Dialysis Center - Clovis - Dialysis	501 N. Medical Center Drive East	Clovis	CA	Terminated
DSH050060AM	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	SPECIAL SERVICES CLINIC - Ambulatory Care at Specialty Services Clinic	2315 E ILLINOIS AVE	FRESNO	CA	Active
DSH050060C	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	CALIFORNIA CANCER CENTER	7257 NORTH FRESNO STREET	FRESNO	CA	Terminated
DSH050060E	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Children's Clinic	290N. Wayte Lane, Suite 1200	Fresno	CA	Terminated
DSH050060F	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Clinic-Family Practice	290 N. Wayte Lane Suite 2100	Fresno	CA	Terminated
DSH050060G	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Clinic-Specialty Services	290 N. Wayte Lane Suite 2200	Fresno	CA	Terminated
DSH050060H	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Clinic-Surgery	255 N. Herwaldt Drive	Fresno	CA	Terminated
DSH050060J	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Clinic-OB/GYN	290 N. Wayte Lane Suite 1200	Fresno	CA	Terminated
DSH050060K	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Dental Clinic	290 N. Wayte Lane Suite 2500	Fresno	CA	Terminated
DSH050060L	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Clinic-Medicine	290 N. Wayte Lane Suite 2300	Fresno	CA	Terminated
DSH050060M	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Clinic-Eye	290 N. Wayte Lane Suite 1400	Fresno	CA	Terminated
DSH050060N	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Ambulatory Infusion Center	2335 East Kashian Lane	Fresno	CA	Active
DSH050060P	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Community Dialysis Center-Fresno	215 N. Fresno Street, ste. 150	Fresno	CA	Active
DSH050060Q	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Dialysis Center at CMC-Clovis	685 Medical Center Drive, suite 105	Clovis	CA	Terminated
DSH050060R	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Neuroscience Outpatient Therapy	2335 Kashian Lane Suite 301	Fresno	CA	Terminated
DSH050060S	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	DISEASE MANAGEMENT CENTER	2315 E ILLINOIS AVE	FRESNO	CA	Terminated
DSH050060T	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Cath Lab	15 E. Audubon Drive	Fresno	CA	Active
DSH050060U	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Cardiology	15 E. Audubon Drive	Fresno	CA	Active
DSH050060V	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	Community Outpatient Oncology	2335 E. Kashian Ln, Suite 301	Fresno	CA	Terminated
DSH050060W	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Advanced Diag test CTR	205 E. Riverpark Circle, suite 160	Fresno	CA	Terminated
DSH050060X	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Clinic Special Services	15 E. Audubon Drive	Fresno	CA	Active
DSH050060Y	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH CT Scanner	15 E. Audubon Drive	Fresno	CA	Active
DSH050060Z	Child	DSH	COMMUNITY REGIONAL MEDICAL CENTER	FH Nuclear Medicine	15 E. Audubon Drive	Fresno	CA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Kiritani, Tracy CFO Community Medical Center 5593244844	Kiritani, Tracy VP Hospital Financial Operations Community Medical Center 5593244844	2/19/2025 7:25 AM
Contacts	Primary Contact	Update	Profile Change Request	Weber, Joel 340B Program Director Community Medical Center 5592311504	Weber, Joel Director of Finance -Pharmacy and 340B Community Medical Center 5592311504	2/18/2025 6:17 PM
Details	Last Recertification Date	Update	Recertification	8/25/2023 2:09:28 PM	8/15/2024 5:08:02 PM	8/15/2024 5:08 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 6:41:05 AM	8/25/2023 2:09:28 PM	8/25/2023 2:09 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 5:11:23 PM	8/31/2022 6:41:05 AM	8/31/2022 6:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/7/2022 1:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		PHB419240	7/7/2022 1:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	7/7/2022 1:28 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	phy 41924 (CA)		7/7/2022 1:28 AM
Details	Last Recertification Date	Update	Recertification	8/24/2020 8:26:07 AM	8/24/2021 5:11:23 PM	8/24/2021 5:11 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1477635191 (CA)		7/19/2021 2:01 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1497836613	5/28/2021 4:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	5/28/2021 4:29 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1104906569	8/24/2020 8:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/24/2020 8:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477635191	8/24/2020 8:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/24/2020 8:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821179656	8/24/2020 8:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/24/2020 8:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1104906569 ( )		8/24/2020 8:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1821179656 ( )		8/24/2020 8:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1497836613 ( )		8/24/2020 8:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1518988575 ( )		8/24/2020 8:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1477635191 ( )		8/24/2020 8:26 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 3:25:07 PM	8/24/2020 8:26:07 AM	8/24/2020 8:26 AM
Addresses	Shipping Address	Delete	Change Request	University Medical Center 290 N. Wayte Lane Suite 1500 Fresno, CA 93701		6/1/2020 7:56 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 2:12:03 PM	8/29/2019 3:25:07 PM	8/29/2019 3:25 PM
Details	Last Recertification Date	Update	Recertification	11/20/2017 2:38:00 PM	8/23/2018 2:12:03 PM	8/23/2018 2:12 PM
Addresses	Shipping Address	Insert	Change Request		COMMUNITY REGIONAL MEDICAL CENTER 2130 EAST ILLINOIS Avenue FRESNO, CA 93701	8/15/2018 10:09 AM
Addresses	Shipping Address	Delete	Change Request	COMMUNITY REGIONAL MEDICAL CENTER 2130 EAST ILLINOIS STREET FRESNO, CA 93701		8/15/2018 10:09 AM
Addresses	Shipping Address	Delete	Change Request	Fresno, Community Hospital PHA Fresno & R Street Fresno, CA 93721		8/15/2018 10:09 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	phB419240	phy 41924	6/25/2018 2:24 PM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/20/2017 2:38:00 PM	11/20/2017 2:38 PM
Contacts	Authorizing Official	Update		Kiritani, Tracy CFO 5593244844	Kiritani, Tracy CFO Community Medical Center 5593244844	9/21/2017 11:28 AM
Contacts	Primary Contact	Update		Weber, Joel 340B Program Director 5592311504	Weber, Joel 340B Program Director Community Medical Center 5592311504	9/18/2017 5:51 PM
Contacts	Primary Contact	Update		Vera, Danny Associate Administrator 5594593110	Weber, Joel 340B Program Director 5592311504	7/12/2017 1:31 PM
Contacts	Authorizing Official	Insert			Kiritani, Tracy CFO 5593244844	7/12/2017 1:31 PM
Addresses	Main Address	Insert			2823 FRESNO STREET FRESNO, CA 93721	7/12/2017 1:31 PM
Addresses	Billing Address	Insert			COMMUNITY REGIONAL MEDICAL CENTER P. O. BOX 1232 FRESNO, CA 93715-1231	7/12/2017 1:31 PM
Addresses	Shipping Address	Insert			COMMUNITY REGIONAL MEDICAL CENTER 2130 EAST ILLINOIS STREET FRESNO, CA 93701	7/12/2017 1:31 PM
Addresses	Shipping Address	Insert			University Medical Center 290 N. Wayte Lane Suite 1500 Fresno, CA 93701	7/12/2017 1:31 PM
Addresses	Shipping Address	Insert			Fresno, Community Hospital PHA Fresno & R Street Fresno, CA 93721	7/12/2017 1:31 PM
Addresses	Shipping Address	Insert			Fresno Heart and Surgical Hospital 15 E. Audubon Drive Fresno, CA 93720-1542	7/12/2017 1:31 PM
Addresses	Shipping Address	Insert			CRMC Infusion Center - Clovis 729 N. Medical Center Drive, West.suite 213 Clovis, CA 93611	7/12/2017 1:31 PM
Addresses	Shipping Address	Insert			Community Home Infusion 1630 E. Shaw Ave, Suite 172 Fresno, CA 93710	7/12/2017 1:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/24/2016 12:24 PM
Medicaid Billing	Medicaid: Number	Insert			phB419240	8/24/2016 12:24 PM
Medicaid Billing	Medicaid: State	Insert			CA	8/24/2016 12:24 PM
Medicaid Billing	NPI: Number	Insert			1104906569	8/24/2016 12:24 PM
Medicaid Billing	NPI: Number	Insert			1821179656	8/24/2016 12:24 PM
Medicaid Billing	NPI: Number	Insert			1497836613	8/24/2016 12:24 PM
Medicaid Billing	NPI: Number	Insert			1518988575	8/24/2016 12:24 PM
Medicaid Billing	NPI: Number	Insert			1477635191	8/24/2016 12:24 PM
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	9/3/2015 2:31 PM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	9/3/2015 12:00:00 AM	9/3/2015 2:31 PM
Contacts	Primary Contact	Insert			Vera, Danny Associate Administrator 5594593110	3/9/2015 11:03 AM
Details	Last Recertification Date	Update		9/3/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 6:30 AM
Details	Last Recertification Date	Update		9/3/2013 4:02:16 PM	9/3/2013 12:00:00 AM	9/5/2013 4:01 PM
Details	Entity Subname	Update		FRESNO COMMUNITY HOSPITAL PHARMACY		9/5/2013 4:01 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/3/2013 4:02:16 PM	9/3/2013 4:02 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/25/2012 10:03 AM
Details	Last Recertification Date	Insert				1/21/2010 3:00 PM
Details	Grant Number	Insert				1/21/2010 3:00 PM
Details	340B ID	Insert			DSH050060	1/21/2010 3:00 PM
Details	Is Authorizing Official EHB Data	Insert				1/21/2010 3:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/21/2010 3:00 PM
Details	Medicare Provider Number	Insert			050060	1/21/2010 3:00 PM
Details	Entity Name	Insert			COMMUNITY REGIONAL MEDICAL CENTER	1/21/2010 3:00 PM
Details	Program Code	Insert			DSH	1/21/2010 3:00 PM
Details	Entity Subname	Insert			FRESNO COMMUNITY HOSPITAL PHARMACY	1/21/2010 3:00 PM
Dates	Participating Approval Date	Insert			3/12/2007 12:00:00 AM	1/21/2010 3:00 PM
Details	State	Insert			Active	1/21/2010 3:00 PM
Dates	Registration Date	Insert			3/12/2007 12:00:00 AM	1/21/2010 3:00 PM
Dates	Signed By Date	Insert			2/20/2007 12:00:00 AM	1/21/2010 3:00 PM
Dates	Start Date	Insert			4/1/2007 12:00:00 AM	1/21/2010 3:00 PM
Terminations	Termination Comments	Insert				1/21/2010 3:00 PM
Terminations	Termination Date	Insert				1/21/2010 3:00 PM
Terminations	Termination Effective Date	Insert				1/21/2010 3:00 PM
Terminations	Termination Reason	Insert				1/21/2010 3:00 PM
Details	Comments Public	Insert			12/17/08 UPDATED ADDR (WAS FRESNO & R STREET); 12/17/08 ADDED SHIP TO; 12/17/08 ADDED BILL TO; 4/1/07 UPDATED ADDR (WAS 2823 FRESNO ST., FRESNO, CA)	1/21/2010 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	3/12/2007 10:12 AM
Medicaid Billing	Medicaid: Number	Insert			HSP40060F	3/12/2007 10:12 AM
Medicaid Billing	Medicaid: State	Insert			CA	3/12/2007 10:12 AM