Covered Entity Details

DSH050485 Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center (Active) - information as of 5/3/2025 11:27:36 PM

Main Details

Name

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

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050485

Medicare Provider Number

050485

Additional Details

Current Program Status

Active

Registration Date

4/22/2008

Participating Start Date

7/1/2004

Participating Approval Date

4/22/2008

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Long Beach Medical Center
Blair Kent, 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

2801 ATLANTIC AVENUE
LONG BEACH, CA 90806

Billing Address

Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center
PO Box 20892
Fountain Valley, CA 92728

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
2/3/12 ADDED SHIP ADD#2, ADDED NPI#	02/03/2012

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

Shipping Address 1

HomeCare Pharmacy
450 E. Spring Street
Suite 11
Long Beach, CA 90806

Shipping Address 2

Infusion Care Pharmacy North
455 E. Columbia Street
Suite 10
Long Beach, CA 90806

Shipping Address 3

Long Beach Memorial Medical Center Outpatient Pharmacy
2801 Atlantic Avenue
LONG BEACH, CA 90806

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	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/20/2023	07/01/2023		07/01/2023
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/09/2023	01/01/2024		01/01/2024
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09587	21761 LAKE FOREST DRIVE	LAKE FOREST	CA	92630	04/20/2023	07/01/2023		07/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08876	233 EAST WILLOW STREET	LONG BEACH	CA	90806	04/20/2023	07/01/2023		07/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09590	6000 ATLANTIC AVENUE	LONG BEACH	CA	90805	04/20/2023	07/01/2023		07/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08878	5505 CARSON ST.	LAKEWOOD	CA	90713	04/20/2023	07/01/2023		07/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09557	1250 E.PACIFIC COAST HIGHWAY	LONG BEACH	CA	90806	04/20/2023	07/01/2023		07/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09505	4400 EAST LOS COYOTES DIAGONAL	LONG BEACH	CA	90815	04/20/2023	07/01/2023		07/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08870	8859 ALONDRA BLVD.	PARAMOUNT	CA	90723	04/20/2023	07/01/2023		07/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09566	596 LONG BEACH BOULEVARD	LONG BEACH	CA	90802	04/20/2023	07/01/2023		07/01/2023
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09123	3800 MARTIN LUTHER KING JR. BOULEVARD	LYNWOOD	CA	90262	04/20/2023	07/01/2023		07/01/2023
Contract Detail	HOMECARE PHARMACY	450 E. Spring Street	Suite 11	Long Beach	CA	90806	07/12/2010	07/12/2010	03/01/2018	03/01/2018
Contract Detail	INFUSION CARE PHARMACY NORTH	455 E COLUMBIA ST	SUITE 10	LONG BEACH	CA	90806	01/12/2015	04/01/2015	03/01/2018	03/01/2018
Contract Detail	LONG BEACH MEMORIAL MEDICAL CENTER	OUTPATIENT PHARMACY	2801 ATLANTIC AVENUE	LONG BEACH	CA	90806-1701	01/06/2015	04/01/2015	03/01/2018	03/01/2018
Contract Detail	LONG BEACH MEMORIAL MEDICAL CENTER	DBA INFUSION CARE PHCY	23521 PASEO DE VALENCIA SUITE B-1	LAGUNA HILLS	CA	92653	04/09/2015	07/01/2015	07/30/2016	07/13/2016
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/19/2024	07/01/2024		07/01/2024
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/19/2024	07/01/2024		07/01/2024
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/20/2023	07/01/2023		07/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/20/2023	07/01/2023		07/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/20/2023	07/01/2023		07/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	04/20/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07481	22930 S WESTERN AVE	TORRANCE	CA	90501	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07870	600 LONG BEACH BLVD	LONG BEACH	CA	90802	10/09/2023	01/01/2024	11/13/2023	12/17/2023
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16482	1902 MARENGO ST UNITS 105 AND 106	LOS ANGELES	CA	90033	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21154	730-740 LONG BEACH BLVD #A & #C	LONG BEACH	CA	90813	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15296	2262 MARKET ST	SAN FRANCISCO	CA	94114	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05616	5913 CARSON ST	LAKEWOOD	CA	90713	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07832	3339 E ANAHEIM ST	LONGBEACH	CA	90804-4032	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05650	2627 PACIFIC AVENUE	LONG BEACH	CA	90806-2610	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07244	3570 ATLANTIC AVE	LONG BEACH	CA	90807-4516	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06903	5829 LAKEWOOD BLVD	LAKEWOOD	CA	90712-1001	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16561	1001 W CARSON ST STE K	TORRANCE	CA	90502	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/09/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/09/2023	01/01/2024		01/01/2024

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	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
Details	Last Recertification Date	Update	Recertification	8/22/2023 12:29:25 AM	8/16/2024 12:10:56 PM	8/16/2024 12:10 PM
Addresses	Billing Address	Insert	Change Request		Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center PO Box 20892 Fountain Valley, CA 92728	6/13/2024 2:47 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 8:21:50 AM	8/22/2023 12:29:25 AM	8/22/2023 12:29 AM
Contacts	Authorizing Official	Update	Change Request	Katz, Yair Chief Executive MCWH SVP Peds MemorialCare Miller Children's and Women's Hospital 5629338008	Pilgrim, Patti Chief Financial Officer MemorialCare Long beach medical Center/Miller children's & Women's Hospital 5629331905	7/10/2023 12:26 PM
Contacts	Authorizing Official	Update	Change Request	Bishop, John Chief Executive Officer Long Beach Medical Center 5629331111	Katz, Yair Chief Executive MCWH SVP Peds MemorialCare Miller Children's and Women's Hospital 5629338008	1/17/2023 10:44 AM
Details	Last Recertification Date	Update	Recertification	8/30/2021 4:19:02 PM	8/29/2022 8:21:50 AM	8/29/2022 8:21 AM
Contacts	Authorizing Official	Update	Change Request	Mmeje, Ikenna (Ike) Chief Operating Officer MemorialCare-Long Beach Medical Center, Miller Children's & Women's Hospital 5629331123	Bishop, John Chief Executive Officer Long Beach Medical Center 5629331111	8/4/2022 11:46 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 11:56:43 AM	8/30/2021 4:19:02 PM	8/30/2021 4:19 PM
Contacts	Primary Contact	Update	Profile Change Request	Chang, Jennifer T Director, Pharmacy Services Long Beach Medical Center & Millier Children's and Women's Hospital 5629330282	Chang, Jennifer T Executive Director, Pharmacy Services Long Beach Medical Center & Millier Children's and Women's Hospital 5629330282	3/2/2021 12:13 PM
Contacts	Authorizing Official	Update	Change Request	Bishop, John Chief Executive Officer Long Beach Medical Center 5629331111	Mmeje, Ikenna (Ike) Chief Operating Officer MemorialCare-Long Beach Medical Center, Miller Children's & Women's Hospital 5629331123	9/28/2020 2:13 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 11:56 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 11:56 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 11:56 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 11:56 AM
Details	Last Recertification Date	Update	Recertification	9/13/2019 7:32:53 AM	9/1/2020 11:56:43 AM	9/1/2020 11:56 AM
Addresses	Shipping Address	Delete	Change Request	LONG BEACH MEMORIAL MEDICAL CENTER 2801 Atlantic Avenue LONG BEACH, CA 90806		3/4/2020 6:29 AM
Addresses	Shipping Address	Insert	Change Request		Infusion Care Pharmacy North 455 E. Columbia Street Suite 10 Long Beach, CA 90806	3/4/2020 6:29 AM
Addresses	Shipping Address	Insert	Change Request		Long Beach Memorial Medical Center Outpatient Pharmacy 2801 Atlantic Avenue LONG BEACH, CA 90806	3/4/2020 6:29 AM
Addresses	Shipping Address	Delete	Change Request	Infusion Care Pharmacy North 455 E. Columbia Street Long Beach, CA 90806		3/4/2020 6:29 AM
Details	Entity Name	Update	Change Request	LONG BEACH MEMORIAL MEDICAL CENTER	Long Beach Memorial Medical Center, Inc. dba MemorialCare Long Beach Medical Center	3/4/2020 6:29 AM
Addresses	Shipping Address	Insert	Recertification		LONG BEACH MEMORIAL MEDICAL CENTER 2801 Atlantic Avenue LONG BEACH, CA 90806	9/13/2019 7:32 AM
Addresses	Shipping Address	Insert	Recertification		HomeCare Pharmacy 450 E. Spring Street Suite 11 Long Beach, CA 90806	9/13/2019 7:32 AM
Addresses	Shipping Address	Delete	Recertification	LONG BEACH MEMORIAL MEDICAL CENTER 2812 LONG BEACH BLVD LONG BEACH, CA 90806		9/13/2019 7:32 AM
Addresses	Shipping Address	Delete	Recertification	HomeCare Pharmacy 450 E. Spring Street Long Beach, CA 90808		9/13/2019 7:32 AM
Details	Last Recertification Date	Update	Recertification	8/17/2018 10:24:02 AM	9/13/2019 7:32:53 AM	9/13/2019 7:32 AM
Contacts	Primary Contact	Update	Change Request	Hodding, Jane Executive Director of Pharmacy Memorialcare Long Beach Medical Center 5629330282	Chang, Jennifer T Director, Pharmacy Services Long Beach Medical Center & Millier Children's and Women's Hospital 5629330282	6/3/2019 9:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/15/2019 8:48 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		HSP40485G	1/15/2019 8:48 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	1/15/2019 8:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/15/2019 8:48 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		HSC40485G	1/15/2019 8:48 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	1/15/2019 8:48 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 3:38:30 PM	8/17/2018 10:24:02 AM	8/17/2018 10:24 AM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	11/15/2017 3:38:30 PM	11/15/2017 3:38 PM
Contacts	Authorizing Official	Update	Profile Change Request	Bishop, John Chief Executive Officer Long Beach Medical Center 5629331905	Bishop, John Chief Executive Officer Long Beach Medical Center 5629331111	10/20/2017 12:22 PM
Contacts	Authorizing Official	Update	Profile Change Request	Bishop, John Chief Financial Officer Long Beach Medical Center 5629331905	Bishop, John Chief Executive Officer Long Beach Medical Center 5629331905	10/20/2017 12:22 PM
Contacts	Authorizing Official	Update		Bishop, John Chief Financial Officer 5629331905	Bishop, John Chief Financial Officer Long Beach Medical Center 5629331905	10/20/2017 12:16 PM
Contacts	Primary Contact	Update		Hodding, Jane Executive Director of Pharmacy 5629330282	Hodding, Jane Executive Director of Pharmacy Memorialcare Long Beach Medical Center 5629330282	10/12/2017 3:49 PM
Contacts	Primary Contact	Update		GELLER, RICHARD EXECUTIVE DIRECTOR OF PHARMACY 5629330328	Hodding, Jane Executive Director of Pharmacy 5629330282	2/16/2017 5:24 PM
Contacts	Authorizing Official	Insert			Bishop, John Chief Financial Officer 5629331905	11/10/2016 8:22 PM
Addresses	Main Address	Insert			2801 ATLANTIC AVENUE LONG BEACH, CA 90806	10/20/2016 2:48 PM
Addresses	Shipping Address	Insert			LONG BEACH MEMORIAL MEDICAL CENTER 2812 LONG BEACH BLVD LONG BEACH, CA 90806	10/20/2016 2:48 PM
Addresses	Shipping Address	Insert			HomeCare Pharmacy 450 E. Spring Street Long Beach, CA 90808	10/20/2016 2:48 PM
Addresses	Shipping Address	Insert			Infusion Care Pharmacy North 455 E. Columbia Street Long Beach, CA 90806	10/20/2016 2:48 PM
Medicaid Billing	NPI: Number	Insert			1053653782	10/20/2016 2:48 PM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/16/2016 12:00:00 AM	8/16/2016 4:57 PM
Medicaid Billing	NPI: Number	Insert			1891890158	4/15/2016 2:22 PM
Medicaid Billing	NPI: Number	Insert			1962442012	4/15/2016 2:22 PM
Details	Last Recertification Date	Update		8/13/2014 12:00:00 AM	8/14/2015 12:00:00 AM	8/14/2015 12:20 PM
Details	Last Recertification Date	Update		8/28/2013 12:00:00 AM	8/13/2014 12:00:00 AM	8/13/2014 2:10 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/28/2013 12:00:00 AM	8/28/2013 6:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/1/2012 7:33 AM
Medicaid Billing	Medicaid: Number	Insert			0247625	5/1/2012 7:33 AM
Medicaid Billing	Medicaid: State	Insert			CA	5/1/2012 7:33 AM
Medicaid Billing	NPI: Number	Update		1891890158	1972514503	5/1/2012 7:33 AM
Contacts	Primary Contact	Update		KAPLAN, TAMRA COO 5629331117	GELLER, RICHARD EXECUTIVE DIRECTOR OF PHARMACY 5629330328	5/1/2012 7:33 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/1/2012 7:33 AM
Details	Entity Subname	Update		PHARMACY		3/23/2012 10:28 AM
Medicaid Billing	NPI: Number	Insert			1891890158	2/3/2012 4:30 PM
Details	Comments Public	Insert			2/3/12 ADDED SHIP ADD#2, ADDED NPI#	2/3/2012 4:30 PM
Contacts	Primary Contact	Insert			KAPLAN, TAMRA COO 5629331117	9/26/2011 12:24 PM
Details	Last Recertification Date	Insert				3/17/2010 10:52 AM
Details	Grant Number	Insert				3/17/2010 10:52 AM
Details	340B ID	Insert			DSH050485	3/17/2010 10:52 AM
Details	Is Authorizing Official EHB Data	Insert				3/17/2010 10:52 AM
Dates	Last Date That 340B Drugs Purchased	Insert				3/17/2010 10:52 AM
Details	Medicare Provider Number	Insert			050485	3/17/2010 10:52 AM
Details	Entity Name	Insert			LONG BEACH MEMORIAL MEDICAL CENTER	3/17/2010 10:52 AM
Details	Program Code	Insert			DSH	3/17/2010 10:52 AM
Details	Entity Subname	Insert			PHARMACY	3/17/2010 10:52 AM
Dates	Participating Approval Date	Insert			4/22/2008 12:00:00 AM	3/17/2010 10:52 AM
Details	State	Insert			Active	3/17/2010 10:52 AM
Dates	Registration Date	Insert			4/22/2008 12:00:00 AM	3/17/2010 10:52 AM
Dates	Signed By Date	Insert				3/17/2010 10:52 AM
Dates	Start Date	Insert			7/1/2004 12:00:00 AM	3/17/2010 10:52 AM
Terminations	Termination Comments	Insert				3/17/2010 10:52 AM
Terminations	Termination Date	Insert				3/17/2010 10:52 AM
Terminations	Termination Effective Date	Insert				3/17/2010 10:52 AM
Terminations	Termination Reason	Insert				3/17/2010 10:52 AM