Covered Entity Details

CAH051320-00 BANNER LASSEN MEDICAL CENTER (Active) - information as of 4/24/2025 11:13:02 PM

Main Details

Name

BANNER LASSEN MEDICAL CENTER

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH051320-00

Medicare Provider Number

051320

Additional Details

Current Program Status

Active

Registration Date

9/3/2010

Participating Start Date

9/20/2010

Participating Approval Date

9/20/2010

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Washakie Medical Center
Jennifer McMillan, Chief Financial Officer
(307) 347-6940

Primary Contact

Banner Lassen Medical Center
Abby Adesanya, Director of Pharmacy
(530) 252-2160

Addresses

Street Address

1800 SPRING RIDGE DRIVE
SUSANVILLE, CA 96130

Billing Address

Banner Health Accounts Payable
PO Box 2977
Phoenix, AZ 85062

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
6/28/2011- DOC.RECD. TO CONFIRM NON-PROFIT STATUS	07/06/2011

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	HSP30251L,HSP40251l	1538197231

Shipping Addresses

Shipping Address 1

BANNER LASSEN MEDICAL CENTER
1800 SPRING RIDGE DRIVE
SUSANVILLE, CA 96130

Shipping Address 2

SAFECOR HEALTH LLC
4060 BUSINESS PARK DR
COLUMBUS, OH 43204

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	BANNER FAMILY PHARMACY-CHANDLER	7300 W DETROIT ST		CHANDLER	AZ	85226-2410	10/28/2015	01/01/2016	09/01/2020	09/01/2020
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	11/28/2012	01/01/2013	03/18/2016	03/18/2016
Contract Detail	OWENS PHARMACY #16	2920 A MAIN ST		SUSANVILLE	CA	96130	10/02/2013	01/01/2014	03/18/2016	03/18/2016
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6105	1615 MAIN STREET	SUSANVILLE	CA	96130	02/15/2013	04/01/2013	03/18/2016	03/18/2016
Contract Detail	WAL-MART PHARMACY 10-1616	2900 MAIN STREET		SUSANVILLE	CA	96130	02/28/2013	04/01/2013	03/18/2016	03/18/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 8:33:17 PM	8/14/2024 1:45:05 PM	8/14/2024 1:45 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 11:51:38 AM	8/23/2023 8:33:17 PM	8/23/2023 8:33 PM
Contacts	Authorizing Official	Update	AO Change Request	Schultz, Lorena CFO Banner Churchill Community Hospital 5302522239	McMillan, Jennifer Chief Financial Officer Washakie Medical Center 3073476940	8/2/2023 10:21 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	908460 (AZ)		12/13/2022 1:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (AZ)		12/13/2022 1:35 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 6:50:10 AM	8/30/2022 11:51:38 AM	8/30/2022 11:51 AM
Contacts	Authorizing Official	Update	Change Request	Fraker, Steven Chief Financial Officer Banner Churchill Community Hospital 7758677002	Schultz, Lorena CFO Banner Churchill Community Hospital 5302522239	6/9/2022 2:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/12/2022 4:37 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		908460	5/12/2022 4:37 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	5/12/2022 4:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	5/12/2022 4:37 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	5/12/2022 4:37 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	908460 (AZ)		2/18/2022 4:57 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1538197231 (NV)		2/18/2022 4:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (AZ)		2/18/2022 4:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (NV)		2/18/2022 4:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/13/2022 7:48 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1538197231	1/13/2022 7:48 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	1/13/2022 7:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	1/13/2022 7:48 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	1/13/2022 7:48 PM
Addresses	Billing Address	Insert	Recertification		Banner Health Accounts Payable PO Box 2977 Phoenix, AZ 85062	8/24/2021 6:50 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 12:28:29 PM	8/24/2021 6:50:10 AM	8/24/2021 6:50 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1538197231 (NV)		6/9/2021 4:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (NV)		6/9/2021 4:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/16/2021 3:34 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1538197231	4/16/2021 3:34 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	4/16/2021 3:34 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	4/16/2021 3:34 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	4/16/2021 3:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	12183B (SC)		1/8/2021 1:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	275015 (OR)		1/8/2021 1:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200586910A (OK)		1/8/2021 1:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	198388401 (TX)		1/8/2021 1:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (OK)		1/8/2021 1:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (TX)		1/8/2021 1:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (OR)		1/8/2021 1:48 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (SC)		1/8/2021 1:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1538197231 (NV)		12/10/2020 5:27 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538197231 (NV)		12/10/2020 5:27 PM
Addresses	Shipping Address	Insert	Change Request		BANNER LASSEN MEDICAL CENTER 1800 SPRING RIDGE DRIVE SUSANVILLE, CA 96130	10/7/2020 1:03 PM
Addresses	Shipping Address	Insert	Change Request		SAFECOR HEALTH LLC 4060 BUSINESS PARK DR COLUMBUS, OH 43204	10/7/2020 1:03 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1538197231 ( )		9/11/2020 12:28 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 6:33:04 AM	9/11/2020 12:28:29 PM	9/11/2020 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1538197231 (OR)		8/11/2020 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/11/2020 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		275015	8/11/2020 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	8/11/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	8/11/2020 4:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	8/11/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	8/11/2020 4:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	8/11/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	8/11/2020 4:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	8/11/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	8/11/2020 4:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	8/11/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	8/11/2020 4:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	8/11/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	8/11/2020 4:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	8/11/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538197231	8/11/2020 4:10 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	8/11/2020 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		908460	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1538197231	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1538197231	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		12183B	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	5/12/2020 7:46 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3004051 (UT)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	908460 (AZ)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	pending (IN)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	pending (MO)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	pending (NM)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	pending (NV)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	pending (OR)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	pending (SC)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	pending (WA)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	pending (WY)		2/18/2020 11:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		908460	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		pending	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		pending	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		pending	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		pending	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		pending	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		pending	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		pending	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		pending	8/27/2019 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WY	8/27/2019 2:51 PM
Details	Last Recertification Date	Update	Recertification	8/21/2018 11:22:59 AM	8/26/2019 6:33:04 AM	8/26/2019 6:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/3/2019 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3004051	7/3/2019 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	7/3/2019 11:18 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	908460 (AZ)		3/4/2019 6:19 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1538197231 (ID)		3/4/2019 6:19 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	275015 (OR)		3/4/2019 6:19 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1092036 (WA)		3/4/2019 6:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2018 7:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1538197231	12/10/2018 7:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	12/10/2018 7:51 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 6:45:23 PM	8/21/2018 11:22:59 AM	8/21/2018 11:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/10/2018 4:11 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		908460	8/10/2018 4:11 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	8/10/2018 4:11 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/20/2018 11:33 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		275015	6/20/2018 11:33 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/20/2018 11:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/20/2018 11:33 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1092036	6/20/2018 11:33 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	6/20/2018 11:33 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	908460 (AZ)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9000145768 (CO)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	920019300 (FL)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	396411133A (GA)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1538197231 (ID)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1457477 (LA)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0514553 (MT)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	275015 (OR)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3024890 (WA)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	14570840 (NM)		4/16/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3004051 (UT)		4/16/2018 4:22 PM
Contacts	Authorizing Official	Update	Change Request	McMillan, Jon CFO of BLMC Banner lassen 5302522239	Fraker, Steven Chief Financial Officer Banner Churchill Community Hospital 7758677002	4/2/2018 7:40 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/22/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		14570840	1/22/2018 4:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	1/22/2018 4:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/22/2018 4:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3004051	1/22/2018 4:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	1/22/2018 4:22 PM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	11/29/2017 6:45:23 PM	11/29/2017 6:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		908460	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000145768	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		920019300	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		396411133A	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1538197231	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1457477	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0514553	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MT	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200586910A	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		275015	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		198388401	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3024890	10/13/2017 1:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	10/13/2017 1:08 PM
Contacts	Authorizing Official	Update		McMillan, Jon CFO of BLMC 5302522239	McMillan, Jon CFO of BLMC Banner lassen 5302522239	10/13/2017 1:05 PM
Contacts	Primary Contact	Update		Adesanya, Abby Director of Pharmacy 5302522160	Adesanya, Abby Director of Pharmacy Banner Lassen Medical Center 5302522160	10/3/2017 3:38 PM
Addresses	Main Address	Insert			1800 SPRING RIDGE DRIVE SUSANVILLE, CA 96130	8/11/2017 3:10 PM
Contacts	Authorizing Official	Update		Harshbarger, Cathy CEO of BLMC 5302522235	McMillan, Jon CFO of BLMC 5302522239	8/11/2017 3:10 PM
Contacts	Primary Contact	Update		Nix, Bob Interim Pharmacy Director 5302522160	Adesanya, Abby Director of Pharmacy 5302522160	8/11/2017 3:10 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/12/2016 5:09 PM
Contacts	Primary Contact	Update		Goldberg, Alan Pharmacy Director 5302522160	Nix, Bob Interim Pharmacy Director 5302522160	8/12/2016 5:09 PM
Details	Last Recertification Date	Update		8/11/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 5:09 PM
Contacts	Authorizing Official	Update		DIEDE, SHELBY CFO 5302522239	Harshbarger, Cathy CEO of BLMC 5302522235	8/3/2016 8:28 PM
Contacts	Primary Contact	Update		Merriman, Charles Pharmacy Director 5302522161	Goldberg, Alan Pharmacy Director 5302522160	3/2/2016 2:34 PM
Details	Last Recertification Date	Update		8/28/2014 12:00:00 AM	8/11/2015 12:00:00 AM	8/11/2015 7:29 AM
Details	Last Recertification Date	Update		8/30/2013 12:00:00 AM	8/28/2014 12:00:00 AM	8/28/2014 1:41 PM
Contacts	Primary Contact	Update		DIEDE, SHELBY CFO 5302522239	Merriman, Charles Pharmacy Director 5302522161	4/29/2014 2:07 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/30/2013 12:00:00 AM	8/30/2013 12:26 PM
Contacts	Authorizing Official	Insert			DIEDE, SHELBY CFO 5302522239	3/5/2013 3:27 PM
Contacts	Primary Contact	Insert			DIEDE, SHELBY CFO 5302522239	3/5/2013 3:27 PM
Medicaid Billing	NPI: Number	Insert			1538197231	5/8/2012 10:31 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/8/2012 10:31 AM
Details	Last Recertification Date	Insert				7/6/2011 5:40 PM
Details	Grant Number	Insert				7/6/2011 5:40 PM
Details	340B ID	Insert			CAH051320-00	7/6/2011 5:40 PM
Details	Is Authorizing Official EHB Data	Insert				7/6/2011 5:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/6/2011 5:40 PM
Details	Medicare Provider Number	Insert			051320	7/6/2011 5:40 PM
Details	Entity Name	Insert			BANNER LASSEN MEDICAL CENTER	7/6/2011 5:40 PM
Details	Program Code	Insert			CAH	7/6/2011 5:40 PM
Details	Entity Subname	Insert				7/6/2011 5:40 PM
Dates	Participating Approval Date	Insert			9/20/2010 12:00:00 AM	7/6/2011 5:40 PM
Details	State	Insert			Active	7/6/2011 5:40 PM
Dates	Registration Date	Insert			9/3/2010 12:00:00 AM	7/6/2011 5:40 PM
Dates	Signed By Date	Insert			9/3/2010 12:00:00 AM	7/6/2011 5:40 PM
Dates	Start Date	Insert			9/20/2010 12:00:00 AM	7/6/2011 5:40 PM
Terminations	Termination Comments	Insert				7/6/2011 5:40 PM
Terminations	Termination Date	Insert				7/6/2011 5:40 PM
Terminations	Termination Effective Date	Insert				7/6/2011 5:40 PM
Terminations	Termination Reason	Insert				7/6/2011 5:40 PM
Details	Comments Public	Insert			6/28/2011- DOC.RECD. TO CONFIRM NON-PROFIT STATUS	7/6/2011 5:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	9/3/2010 2:18 PM
Medicaid Billing	Medicaid: Number	Insert			HSP30251L	9/3/2010 2:18 PM
Medicaid Billing	Medicaid: State	Insert			CA	9/3/2010 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/3/2010 2:18 PM
Medicaid Billing	Medicaid: Number	Insert			HSP40251l	9/3/2010 2:18 PM
Medicaid Billing	Medicaid: State	Insert			CA	9/3/2010 2:18 PM