| Details | Last Recertification Date | Update | Recertification | 2/1/2024 3:43:00 PM | 2/14/2025 5:51:45 PM | 2/14/2025 5:51 PM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2023 11:20:30 AM | 2/1/2024 3:43:00 PM | 2/1/2024 3:43 PM |
| Details | Last Recertification Date | Update | Recertification | 2/2/2022 12:56:43 PM | 2/1/2023 11:20:30 AM | 2/1/2023 11:20 AM |
| Addresses | Billing Address | Update | Change Request | Center for Inherited Blood Disorders - Admin
2670 N. Main St.
Suite 150
Santa Ana, CA 92705 | Center for Inherited Blood Disorders - Admin
701 S. Parker Street
Suite 1200
Orange, CA 92868 | 5/24/2022 2:12 PM |
| Addresses | Shipping Address | Update | Change Request | CIBD PHARMACY
2670 NORTH MAIN ST.
SUITE 150
SANTA ANA, CA 92705 | CIBD PHARMACY
701 S. Parker Street
SUITE 1400
Orange, CA 92868 | 5/24/2022 2:12 PM |
| Addresses | Main Address | Update | Change Request |
1010 W. La Veta Ave
SUITE 670
Orange, CA 92868 |
701 S. Parker Street
Suite 1000
Orange, CA 92868 | 3/10/2022 8:21 AM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2021 4:35:40 PM | 2/2/2022 12:56:43 PM | 2/2/2022 12:56 PM |
| Details | Last Recertification Date | Update | Recertification | 1/28/2020 5:18:30 PM | 2/3/2021 4:35:40 PM | 2/3/2021 4:35 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1679875942 ( ) | | 1/18/2021 8:11 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1598067613 | 1/18/2021 8:11 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | CA | 1/18/2021 8:11 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1679875942 | 1/18/2021 8:11 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | CA | 1/18/2021 8:11 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1598067613 ( ) | | 1/18/2021 8:11 PM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2019 12:46:36 PM | 1/28/2020 5:18:30 PM | 1/28/2020 5:18 PM |
| Contacts | Primary Contact | Update | Change Request | Zamora, Jason
Pharmacy Director
Center for Comprehensive Care and Diagnosis of Inherited Blood Disorders
9492220325 | Gillespie, Lori
340B Pharmacy Coordinator
CIBD Pharmacy
6572328113 | 7/1/2019 11:54 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2018 7:46:14 PM | 2/5/2019 12:46:36 PM | 2/5/2019 12:46 PM |
| Details | Last Recertification Date | Update | Recertification | 1/26/2017 12:00:00 AM | 2/13/2018 7:46:14 PM | 2/13/2018 7:46 PM |
| Contacts | Primary Contact | Update | | Zamora, Jason
Pharmacy Director
9492220325 | Zamora, Jason
Pharmacy Director
Center for Comprehensive Care and Diagnosis of Inherited Blood Disorders
9492220325 | 9/28/2017 6:52 PM |
| Contacts | Authorizing Official | Update | | NUGENT, DIANE
DIRECTOR, HEMOPHILIA TREATMENT CENTER
7145098744 | NUGENT, DIANE
DIRECTOR, HEMOPHILIA TREATMENT CENTER
Center for Comprehensive Care and Diagnosis of Inherited Blood Disorders
7145098744 | 9/28/2017 6:37 PM |
| Contacts | Primary Contact | Insert | | | Zamora, Jason
Pharmacy Director
9492220325 | 2/1/2017 5:32 PM |
| Addresses | Main Address | Insert | | |
1010 W. La Veta Ave
SUITE 670
Orange, CA 92868 | 1/26/2017 7:14 PM |
| Contacts | Authorizing Official | Insert | | | NUGENT, DIANE
DIRECTOR, HEMOPHILIA TREATMENT CENTER
7145098744 | 1/26/2017 7:14 PM |
| Details | Last Recertification Date | Update | | 2/29/2016 12:00:00 AM | 1/26/2017 12:00:00 AM | 1/26/2017 7:14 PM |
| Addresses | Billing Address | Insert | | | Center for Inherited Blood Disorders - Admin
2670 N. Main St.
Suite 150
Santa Ana, CA 92705 | 5/31/2016 5:02 PM |
| Addresses | Shipping Address | Insert | | | CIBD PHARMACY
2670 NORTH MAIN ST.
SUITE 150
SANTA ANA, CA 92705 | 5/31/2016 5:02 PM |
| Details | Last Recertification Date | Update | | 2/27/2015 12:00:00 AM | 2/29/2016 12:00:00 AM | 2/29/2016 1:49 PM |
| Details | Last Recertification Date | Update | | 2/10/2014 12:00:00 AM | 2/27/2015 12:00:00 AM | 2/27/2015 12:37 PM |
| Details | Grant Number | Update | | H30MC21656 | H30MC24045 | 2/27/2015 12:37 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 2/10/2014 12:00:00 AM | 2/10/2014 9:55 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 3/19/2013 9:42 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 1598067613 | 3/19/2013 9:42 AM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 3/19/2013 9:42 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1598067613 | 3/19/2013 9:42 AM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/11/2013 7:17 AM |
| Medicaid Billing | Medicaid: Number | Update | | 167987594 | 1679875942 | 1/10/2013 6:47 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/9/2013 1:34 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 167987594 | 1/9/2013 1:34 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 1/9/2013 1:34 PM |
| Medicaid Billing | NPI: Number | Update | | 1598067613 | 1679875942 | 5/4/2012 1:31 PM |
| Details | Grant Number | Update | | | H30MC21656 | 5/4/2012 1:29 PM |
| Details | Grant Number | Update | | H30MC00036 | | 5/18/2011 5:42 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1598067613 | 7/1/1997 12:00 AM |
| Details | Last Recertification Date | Insert | | | | 7/1/1997 12:00 AM |
| Details | Grant Number | Insert | | | H30MC00036 | 7/1/1997 12:00 AM |
| Details | 340B ID | Insert | | | HM92668 | 7/1/1997 12:00 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/1/1997 12:00 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/1/1997 12:00 AM |
| Details | Medicare Provider Number | Insert | | | | 7/1/1997 12:00 AM |
| Details | Entity Name | Insert | | | CENTER FOR COMPREHENSIVE CARE & DIAGNOSIS OF INHERITED BLOOD DISORDERS (CIBD) | 7/1/1997 12:00 AM |
| Details | Program Code | Insert | | | HM | 7/1/1997 12:00 AM |
| Details | Entity Subname | Insert | | | | 7/1/1997 12:00 AM |
| Dates | Participating Approval Date | Insert | | | 2/3/2005 12:00:00 AM | 7/1/1997 12:00 AM |
| Details | State | Insert | | | Active | 7/1/1997 12:00 AM |
| Dates | Registration Date | Insert | | | 7/1/1997 12:00:00 AM | 7/1/1997 12:00 AM |
| Dates | Signed By Date | Insert | | | 5/1/2011 12:00:00 AM | 7/1/1997 12:00 AM |
| Dates | Start Date | Insert | | | 7/1/1997 12:00:00 AM | 7/1/1997 12:00 AM |
| Terminations | Termination Comments | Insert | | | | 7/1/1997 12:00 AM |
| Terminations | Termination Date | Insert | | | | 7/1/1997 12:00 AM |
| Terminations | Termination Effective Date | Insert | | | | 7/1/1997 12:00 AM |
| Terminations | Termination Reason | Insert | | | | 7/1/1997 12:00 AM |
| Details | Comments Public | Insert | | | 5/18/11 ENTITY NAME/ADDR/MEDI # CHANGE (WAS CHILDREN'S HOSPITAL OF ORANGE COUNTY/455 SOUTH MAIN STREET/PHA372150) 5/17/11 ADMIN CORRECTION TO RESTORE ELIGIBILITY(GRANT FUNDING CONFIRMED); 2/3/05 - ADDED EMAIL, ADDED MEDICAID # | 7/1/1997 12:00 AM |