| Medicaid Billing | NPI: Number | Delete | Change Request | 1043406440 (CA) | | 2/12/2025 11:23 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2023 1:46:31 PM | 8/21/2024 11:19:36 AM | 8/21/2024 11:19 AM |
| Details | Last Recertification Date | Update | Recertification | 9/12/2022 9:48:56 AM | 8/29/2023 1:46:31 PM | 8/29/2023 1:46 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Asuming, Winna
Pharmacy Operations Manager
St. Mary Medical Center
7602422311-4238 | Asuming, Winna
Director of Pharmacy
St Mary Medical Center
7609464238 | 1/11/2023 7:19 AM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2021 11:36:49 AM | 9/12/2022 9:48:56 AM | 9/12/2022 9:48 AM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2020 12:38:59 PM | 9/7/2021 11:36:49 AM | 9/7/2021 11:36 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 9/1/2020 12:38 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 9/1/2020 12:38 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 9/1/2020 12:38 PM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2019 8:27:09 PM | 9/1/2020 12:38:59 PM | 9/1/2020 12:38 PM |
| Contacts | Authorizing Official | Update | Change Request | Fernandez, Tracey
VP /CFO
St. Mary Medical Center
7602422311-8727 | Gutierrez, Eugene
Chief Financial Officer
St Mary Medical Center
7609468105 | 7/13/2020 4:58 PM |
| Addresses | Billing Address | Update | Change Request | St. Mary Medical Center
PO Box 31001 1946
Pasadena, CA 91111 | St. Mary Medical Center
PO BOX 696431
SAN ANTONIO, TX 78269 | 10/2/2019 11:53 AM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 3:44:10 PM | 8/21/2019 8:27:09 PM | 8/21/2019 8:27 PM |
| Addresses | Shipping Address | Delete | Change Request | St. Mary Medical Center
16000 Kasota Rd.
Apple Valley, CA 92307 | | 2/14/2019 12:31 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Asuming, Winna
Pharmacy Manager
St. Mary Medical Center
7602422311-4238 | Asuming, Winna
Pharmacy Operations Manager
St. Mary Medical Center
7602422311-4238 | 2/12/2019 9:14 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/10/2018 5:35 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | ZZT40300F | 10/10/2018 5:35 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | CA | 10/10/2018 5:35 PM |
| Details | Last Recertification Date | Update | Recertification | 11/9/2017 12:35:11 PM | 8/22/2018 3:44:10 PM | 8/22/2018 3:44 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1043406440 | 4/11/2018 12:48 PM |
| Addresses | Shipping Address | Insert | Change Request | | St Mary Medical Center
18300 US Highway 18
Apple Valley, CA 92307 | 2/2/2018 8:51 AM |
| Contacts | Primary Contact | Update | Recertification | Fernandez, Tracey
VP /CFO
7602422311-8727 | Asuming, Winna
Pharmacy Manager
St. Mary Medical Center
7602422311-4238 | 11/9/2017 12:35 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2016 12:00:00 AM | 11/9/2017 12:35:11 PM | 11/9/2017 12:35 PM |
| Contacts | Authorizing Official | Update | | Fernandez, Tracey
VP /CFO
7602422311-8727 | Fernandez, Tracey
VP /CFO
St. Mary Medical Center
7602422311-8727 | 10/2/2017 3:00 PM |
| Addresses | Main Address | Insert | | |
18300 US HIGHWAY 18
APPLE VALLEY, CA 92307 | 8/16/2016 1:38 PM |
| Contacts | Authorizing Official | Update | | WONG, EDWARD
VICE PRESIDENT OF FINANCE/CFO
7609468727 | Fernandez, Tracey
VP /CFO
7602422311-8727 | 8/16/2016 1:38 PM |
| Contacts | Primary Contact | Update | | HUANG, VANBOTRA
DIRECTOR OF PHARMACY
7602422311-5300 | Fernandez, Tracey
VP /CFO
7602422311-8727 | 8/16/2016 1:38 PM |
| Details | Last Recertification Date | Update | | 8/25/2015 12:00:00 AM | 8/16/2016 12:00:00 AM | 8/16/2016 1:38 PM |
| Addresses | Billing Address | Insert | | | St. Mary Medical Center
PO Box 31001 1946
Pasadena, CA 91111 | 11/19/2015 12:30 PM |
| Addresses | Shipping Address | Insert | | | St. Mary Medical Center
16000 Kasota Rd.
Apple Valley, CA 92307 | 11/19/2015 12:30 PM |
| Medicaid Billing | Medicaid: Is Primary | Update | | True | False | 8/25/2015 4:24 PM |
| Details | Last Recertification Date | Update | | 9/4/2014 12:00:00 AM | 8/25/2015 12:00:00 AM | 8/25/2015 4:24 PM |
| Details | Last Recertification Date | Update | | 9/13/2013 12:00:00 AM | 9/4/2014 12:00:00 AM | 9/4/2014 1:14 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1669456299 | 9/13/2013 11:40 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1710109186 | 9/13/2013 11:40 AM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 9/13/2013 12:00:00 AM | 9/13/2013 11:40 AM |
| Contacts | Primary Contact | Insert | | | HUANG, VANBOTRA
DIRECTOR OF PHARMACY
7602422311-5300 | 5/3/2012 7:59 AM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 5/3/2012 7:59 AM |
| Contacts | Authorizing Official | Insert | | | WONG, EDWARD
VICE PRESIDENT OF FINANCE/CFO
7609468727 | 9/14/2010 10:23 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | True | 9/2/2010 3:02 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | ZZT30300F | 9/2/2010 3:02 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 9/2/2010 3:02 PM |
| Details | Last Recertification Date | Insert | | | | 9/2/2010 3:02 PM |
| Details | Grant Number | Insert | | | | 9/2/2010 3:02 PM |
| Details | 340B ID | Insert | | | DSH050300 | 9/2/2010 3:02 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 9/2/2010 3:02 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 9/2/2010 3:02 PM |
| Details | Medicare Provider Number | Insert | | | 050300 | 9/2/2010 3:02 PM |
| Details | Entity Name | Insert | | | ST. MARY MEDICAL CENTER | 9/2/2010 3:02 PM |
| Details | Program Code | Insert | | | DSH | 9/2/2010 3:02 PM |
| Details | Entity Subname | Insert | | | | 9/2/2010 3:02 PM |
| Dates | Participating Approval Date | Insert | | | 9/14/2010 12:00:00 AM | 9/2/2010 3:02 PM |
| Details | State | Insert | | | Active | 9/2/2010 3:02 PM |
| Dates | Registration Date | Insert | | | 9/2/2010 12:00:00 AM | 9/2/2010 3:02 PM |
| Dates | Signed By Date | Insert | | | 3/29/2010 12:00:00 AM | 9/2/2010 3:02 PM |
| Dates | Start Date | Insert | | | 10/1/2010 12:00:00 AM | 9/2/2010 3:02 PM |
| Terminations | Termination Comments | Insert | | | | 9/2/2010 3:02 PM |
| Terminations | Termination Date | Insert | | | | 9/2/2010 3:02 PM |
| Terminations | Termination Effective Date | Insert | | | | 9/2/2010 3:02 PM |
| Terminations | Termination Reason | Insert | | | | 9/2/2010 3:02 PM |