Covered Entity Details

DSH120002 MAUI HEALTH SYSTEM, A KAISER FOUNDATION HOSPITALS, LLC, dba Maui Memorial Medical Center (Active) - information as of 5/1/2025 11:52:26 PM

Main Details

Name

MAUI HEALTH SYSTEM, A KAISER FOUNDATION HOSPITALS, LLC, dba Maui Memorial Medical Center

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH120002

Medicare Provider Number

120002

Additional Details

Current Program Status

Active

Registration Date

12/15/2008

Participating Start Date

1/1/2009

Participating Approval Date

12/15/2008

Last Recertification Date

9/9/2024

Contacts

Authorizing Official

Maui Health System, A Kaiser Foundation Hospitals, LLC
Wade Ebersole, COO
(808) 264-3312

Primary Contact

Maui Health System, A Kaiser Foundation Hospitals, LLC
Daniel Navas, Director of Pharmacy
(808) 242-2120

Addresses

Street Address

221 MAHALANI ST
WAILUKU, HI 96793

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
12/08- DOC RECD TO CONFIRM ELIGIBLE DSH ADJ%; PREV PART AS DSH96793 FROM 1/1/2005 - 6/30/2007, INELIG 7/1/2007 TO 12/31/2008	12/15/2008

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
AK	1702715	1013379460
HI	803678	1013379460
WA	2141078	1013379460
MT	1013379460	1013379460
NV	1013379460	1013379460
CA	1013379460	1013379460
GA	1013379460	1013379460
OH	2340103	1013379460
TX	1013379460	1013379460
VT	1013379460	1013379460
NM	70606323	1013379460
UT	3012689	1013379460
CO	9000236489	1013379460
MI	1013379460	1013379460
AR		1013379460
AZ		1013379460
CT		1013379460
FL		1013379460
ID		1013379460
IL		1013379460
LA		1013379460
MA		1013379460
MD		1013379460
MO		1013379460
NC		1013379460
NE		1013379460
NH		1013379460
NJ		1013379460
NY		1013379460
OK		1013379460
OR		1013379460
PA		1013379460
WI		1013379460
WV		1013379460
IA		1013379460
IN		1013379460
MN		1013379460
MS		1013379460
TN		1013379460

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH120002A	Child	DSH	MAUI HEALTH SYSTEM, A KAISER FOUNDATION HOSPITALS, LLC, dba Maui Memorial Medical Center	MAUI MEMORIAL MEDICAL CENTER OUTPATIENT CLINIC - MAUI MEMORIAL MEDICAL CENTER OUTPATIENT CLINIC	85 MAUI LANI PARKWAY	WAILUKU	HI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/15/2024 7:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3012689	11/15/2024 7:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	11/15/2024 7:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/15/2024 7:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000236489	11/15/2024 7:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	11/15/2024 7:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/15/2024 7:18 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1013379460	11/15/2024 7:18 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	11/15/2024 7:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	11/15/2024 7:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	11/15/2024 7:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	11/15/2024 7:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	11/15/2024 7:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	11/15/2024 7:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	11/15/2024 7:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	11/15/2024 7:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	11/15/2024 7:18 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	11/15/2024 7:18 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	11/15/2024 7:18 PM
Details	Last Recertification Date	Update	Recertification	8/22/2023 4:31:44 PM	9/9/2024 6:26:28 AM	9/9/2024 6:26 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1013379460 (UT)		4/2/2024 5:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/2/2024 5:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		70606323	4/2/2024 5:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		AK	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	4/2/2024 5:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013379460	4/2/2024 5:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	4/2/2024 5:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1013379460	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MT	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1013379460	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1013379460	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1013379460	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2340103	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1013379460	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1013379460	2/19/2024 12:53 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	2/19/2024 12:53 PM
Details	Last Recertification Date	Update	Recertification	9/7/2022 10:31:37 AM	8/22/2023 4:31:44 PM	8/22/2023 4:31 PM
Contacts	Primary Contact	Update	Profile Change Request	Navas, Daniel Director of Pharmacy Maui Health System, A Kiaser Foundation Hospitals, LLC 8082422120	Navas, Daniel Director of Pharmacy Maui Health System, A Kaiser Foundation Hospitals, LLC 8082422120	11/17/2022 3:35 PM
Details	Last Recertification Date	Update	Recertification	8/22/2021 9:48:04 PM	9/7/2022 10:31:37 AM	9/7/2022 10:31 AM
Contacts	Authorizing Official	Update	Change Request	Tamori, Joyce Chief Financial Officer Maui Health System, A Kaiser Foundation Hospitals LLC 8082433095	Ebersole, Wade COO Maui Health System, A Kaiser Foundation Hospitals, LLC 8082643312	8/8/2022 10:59 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/6/2021 11:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2141078	12/6/2021 11:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	12/6/2021 11:24 PM
Details	Last Recertification Date	Update	Recertification	9/14/2020 1:30:21 PM	8/22/2021 9:48:04 PM	8/22/2021 9:48 PM
Addresses	Main Address	Update	Change Request	221 MAHALANI STREET WAILUKU, HI 96793	221 MAHALANI ST WAILUKU, HI 96793	12/13/2020 3:51 PM
Medicaid Billing	NPI: State	Update	Recertification		HI	9/14/2020 1:30 PM
Details	Last Recertification Date	Update	Recertification	9/13/2019 7:48:10 AM	9/14/2020 1:30:21 PM	9/14/2020 1:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/10/2020 7:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1702715	7/10/2020 7:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AK	7/10/2020 7:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/10/2020 7:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1013379460	7/10/2020 7:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	7/10/2020 7:17 PM
Details	Entity Name	Update	Change Request	MAUI HEALTH SYSTEM, A KAISER FOUNDATION HOSPITALS, LLC	MAUI HEALTH SYSTEM, A KAISER FOUNDATION HOSPITALS, LLC, dba Maui Memorial Medical Center	10/31/2019 8:48 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 10:11:48 AM	9/13/2019 7:48:10 AM	9/13/2019 7:48 AM
Contacts	Authorizing Official	Update	Profile Change Request	Tamori, Joyce Chief Financial Officer Maui Health System 8082433095	Tamori, Joyce Chief Financial Officer Maui Health System, A Kaiser Foundation Hospitals LLC 8082433095	3/12/2019 4:07 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	005796	803678	3/12/2019 4:05 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 4:44:49 PM	8/22/2018 10:11:48 AM	8/22/2018 10:11 AM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	12/4/2017 4:44:49 PM	12/4/2017 4:44 PM
Contacts	Primary Contact	Update		Navas, Daniel Director of Pharmacy 8082422120	Navas, Daniel Director of Pharmacy Maui Health System, A Kiaser Foundation Hospitals, LLC 8082422120	11/16/2017 12:13 PM
Contacts	Authorizing Official	Update		Tamori, Joyce Chief Financial Officer 8082433095	Tamori, Joyce Chief Financial Officer Maui Health System 8082433095	10/25/2017 2:48 PM
Addresses	Main Address	Insert			221 MAHALANI STREET WAILUKU, HI 96793	7/18/2017 8:21 AM
Contacts	Authorizing Official	Update		Tamori, Joyce Chief Financial Officer 8082433095	Tamori, Joyce Chief Financial Officer 8082433095	7/18/2017 8:21 AM
Contacts	Primary Contact	Update		Navas, Daniel Director of Pharmacy 8082422120	Navas, Daniel Director of Pharmacy 8082422120	7/18/2017 8:21 AM
Medicaid Billing	NPI: Number	Update		1629167754	1013379460	7/18/2017 8:20 AM
Details	Entity Name	Update		MAUI MEMORIAL MEDICAL CENTER	MAUI HEALTH SYSTEM, A KAISER FOUNDATION HOSPITALS, LLC	7/18/2017 8:20 AM
Contacts	Authorizing Official	Update		Oldenburg, Beth Fiscal Management Officer 8082433095	Tamori, Joyce Chief Financial Officer 8082433095	5/9/2017 12:00 PM
Contacts	Primary Contact	Insert			Navas, Daniel Director of Pharmacy 8082422120	5/9/2017 12:00 PM
Contacts	Authorizing Official	Update		Hughey, Nick Regional Chief Business Officer 8084425276	Oldenburg, Beth Fiscal Management Officer 8082433095	8/22/2016 9:27 PM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 9:27 PM
Details	Last Recertification Date	Update		9/9/2014 12:00:00 AM	8/24/2015 12:00:00 AM	8/24/2015 5:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/9/2014 7:56 AM
Medicaid Billing	Medicaid: Number	Insert			005796	9/9/2014 7:56 AM
Medicaid Billing	Medicaid: State	Insert			HI	9/9/2014 7:56 AM
Contacts	Authorizing Official	Update		Devine, Kirsten Interim CFO 8082433095	Hughey, Nick Regional Chief Business Officer 8084425276	9/9/2014 7:56 AM
Details	Last Recertification Date	Update		9/13/2013 12:00:00 AM	9/9/2014 12:00:00 AM	9/9/2014 7:56 AM
Contacts	Authorizing Official	Update		LO, WESLEY REGIONAL CHIEF EXECUTIVE OFFICER 8082422027	Devine, Kirsten Interim CFO 8082433095	7/3/2014 4:20 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/13/2013 12:00:00 AM	9/13/2013 3:31 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/15/2012 7:31 AM
Contacts	Authorizing Official	Insert			LO, WESLEY REGIONAL CHIEF EXECUTIVE OFFICER 8082422027	12/15/2008 1:28 PM
Details	Last Recertification Date	Insert				12/15/2008 1:28 PM
Details	Grant Number	Insert				12/15/2008 1:28 PM
Details	340B ID	Insert			DSH120002	12/15/2008 1:28 PM
Details	Is Authorizing Official EHB Data	Insert				12/15/2008 1:28 PM
Dates	Last Date That 340B Drugs Purchased	Insert				12/15/2008 1:28 PM
Details	Medicare Provider Number	Insert			120002	12/15/2008 1:28 PM
Details	Entity Name	Insert			MAUI MEMORIAL MEDICAL CENTER	12/15/2008 1:28 PM
Details	Program Code	Insert			DSH	12/15/2008 1:28 PM
Details	Entity Subname	Insert				12/15/2008 1:28 PM
Dates	Participating Approval Date	Insert			12/15/2008 12:00:00 AM	12/15/2008 1:28 PM
Details	State	Insert			Active	12/15/2008 1:28 PM
Dates	Registration Date	Insert			12/15/2008 12:00:00 AM	12/15/2008 1:28 PM
Dates	Signed By Date	Insert			11/26/2008 12:00:00 AM	12/15/2008 1:28 PM
Dates	Start Date	Insert			1/1/2009 12:00:00 AM	12/15/2008 1:28 PM
Terminations	Termination Comments	Insert				12/15/2008 1:28 PM
Terminations	Termination Date	Insert				12/15/2008 1:28 PM
Terminations	Termination Effective Date	Insert				12/15/2008 1:28 PM
Terminations	Termination Reason	Insert				12/15/2008 1:28 PM
Details	Comments Public	Insert			12/08- DOC RECD TO CONFIRM ELIGIBLE DSH ADJ%; PREV PART AS DSH96793 FROM 1/1/2005 - 6/30/2007, INELIG 7/1/2007 TO 12/31/2008	12/15/2008 1:28 PM
Medicaid Billing	NPI: Number	Insert			1629167754	12/15/2008 12:50 PM