| Contacts | Primary Contact | Update | PC Change Request | Lewis, Myron Ray
Director of Pharmacy
University Medical Center of El Paso
9155217662 | CHAN, DAVID
Asst Administrator Pharmacy Services
UNIVERSITY MEDICAL CENTER OF EL PASO
9155217662 | 10/31/2024 7:06 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2023 9:45:34 AM | 8/13/2024 8:30:31 AM | 8/13/2024 8:30 AM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2022 8:57:31 AM | 8/16/2023 9:45:34 AM | 8/16/2023 9:45 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2021 4:15:08 PM | 8/31/2022 8:57:31 AM | 8/31/2022 8:57 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2020 2:31:42 PM | 8/18/2021 4:15:08 PM | 8/18/2021 4:15 PM |
| Contacts | Signed By | Update | Change Request | Nunez, Michael
CFO
9155217626 | Nunez, Michael L.
District CFO
University Medical Center of El Paso
9155217626 | 8/13/2021 4:48 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | TX | 8/27/2020 2:31 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | TX | 8/27/2020 2:31 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | TX | 8/27/2020 2:31 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | TX | 8/27/2020 2:31 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2019 1:01:30 PM | 8/27/2020 2:31:42 PM | 8/27/2020 2:31 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1275784910 | 1/7/2020 1:17 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/7/2019 10:47 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 092072002 | 10/7/2019 10:47 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | TX | 10/7/2019 10:47 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/7/2019 10:47 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 138951211 | 10/7/2019 10:47 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | TX | 10/7/2019 10:47 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1811135080 | 10/7/2019 10:47 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1316936990 | 10/7/2019 10:47 AM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 9:48:03 AM | 8/23/2019 1:01:30 PM | 8/23/2019 1:01 PM |
| Addresses | Shipping Address | Insert | Change Request | | University Medical Center Pharmacy Fabens
101 Potasio ST
El Paso, TX 79838 | 11/7/2018 3:55 PM |
| Addresses | Main Address | Update | Change Request |
101 Potasio
Fabens, TX 79838 |
101 Potasio ST
Fabens, TX 79838 | 11/7/2018 3:55 PM |
| Addresses | Shipping Address | Delete | Change Request | University Medical Center Pharmacy Fabens
101 Potassio
El Paso, TX 79838 | | 11/7/2018 3:55 PM |
| Details | Entity Subname | Update | Change Request | UMC Neighborhood Health Center Fabens | University Medical Center Fabens | 11/7/2018 3:55 PM |
| Details | Last Recertification Date | Update | Recertification | 11/13/2017 4:09:59 PM | 8/22/2018 9:48:03 AM | 8/22/2018 9:48 AM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2016 12:00:00 AM | 11/13/2017 4:09:59 PM | 11/13/2017 4:09 PM |
| Contacts | Authorizing Official | Update | | NUNEZ, MICHAEL
CFO
9155217626 | NUNEZ, MICHAEL
CFO
University Medical Center of El Paso
9155217626 | 9/29/2017 3:38 PM |
| Contacts | Primary Contact | Update | | Lewis, Myron
Director of Pharmacy
9155217662 | Lewis, Myron Ray
Director of Pharmacy
University Medical Center of El Paso
9155217662 | 9/29/2017 7:59 AM |
| Addresses | Main Address | Insert | | |
101 Potasio
Fabens, TX 79838 | 5/2/2017 2:51 PM |
| Addresses | Shipping Address | Insert | | | University Medical Center Pharmacy Fabens
101 Potassio
El Paso, TX 79838 | 5/2/2017 2:51 PM |
| Contacts | Signed By | Insert | | | Nunez, Michael
CFO
9155217626 | 5/2/2017 2:51 PM |
| Contacts | Primary Contact | Insert | | | Lewis, Myron
Director of Pharmacy
9155217662 | 5/2/2017 2:51 PM |
| Contacts | Authorizing Official | Insert | | | NUNEZ, MICHAEL
CFO
9155217626 | 5/2/2017 2:51 PM |
| Medicaid Billing | Medicaid: Number | Update | | 5908491 | 251002 | 5/2/2017 2:50 PM |
| Details | Last Recertification Date | Update | | 8/14/2015 12:00:00 AM | 9/2/2016 12:00:00 AM | 9/2/2016 11:03 AM |
| Medicaid Billing | Medicaid: Number | Update | | 250489 | 5908491 | 6/30/2016 11:09 AM |
| Details | Last Recertification Date | Update | | 8/21/2014 12:00:00 AM | 8/14/2015 12:00:00 AM | 8/14/2015 5:36 PM |
| Details | Last Recertification Date | Update | | 9/6/2013 12:00:00 AM | 8/21/2014 12:00:00 AM | 8/21/2014 1:22 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/6/2014 11:17 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 250489 | 1/6/2014 11:17 AM |
| Medicaid Billing | Medicaid: State | Insert | | | TX | 1/6/2014 11:17 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1124360748 | 1/6/2014 11:17 AM |
| Details | Last Recertification Date | Update | | 9/6/2013 1:30:56 PM | 9/6/2013 12:00:00 AM | 1/6/2014 11:17 AM |
| Details | Last Recertification Date | Update | | | 9/6/2013 1:30:56 PM | 9/6/2013 1:30 PM |
| Dates | Participating Approval Date | Update | | | 6/25/2012 12:00:00 AM | 6/25/2012 8:57 AM |
| Details | State | Update | | Pending | Active | 6/25/2012 8:57 AM |
| Dates | Start Date | Update | | | 7/1/2012 12:00:00 AM | 6/25/2012 8:57 AM |
| Details | 340B ID | Update | | IS-DR-DSH450024D | DSH450024D | 6/21/2012 1:39 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | IS-DR-DSH450024D | 5/17/2012 11:35 AM |
| Details | Last Recertification Date | Insert | | | | 5/3/2012 6:52 PM |
| Details | Grant Number | Insert | | | | 5/3/2012 6:52 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 5/3/2012 6:52 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 5/3/2012 6:52 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 5/3/2012 6:52 PM |
| Details | Medicare Provider Number | Insert | | | 450024 | 5/3/2012 6:52 PM |
| Details | Entity Name | Insert | | | UNIVERSITY MEDICAL CENTER OF EL PASO | 5/3/2012 6:52 PM |
| Details | Program Code | Insert | | | DSH | 5/3/2012 6:52 PM |
| Details | Entity Subname | Insert | | | UMC Neighborhood Health Center Fabens | 5/3/2012 6:52 PM |
| Dates | Participating Approval Date | Insert | | | | 5/3/2012 6:52 PM |
| Details | State | Insert | | | Pending | 5/3/2012 6:52 PM |
| Dates | Registration Date | Insert | | | 5/3/2012 12:00:00 AM | 5/3/2012 6:52 PM |
| Dates | Signed By Date | Insert | | | 5/3/2012 12:00:00 AM | 5/3/2012 6:52 PM |
| Dates | Start Date | Insert | | | | 5/3/2012 6:52 PM |
| Terminations | Termination Comments | Insert | | | | 5/3/2012 6:52 PM |
| Terminations | Termination Date | Insert | | | | 5/3/2012 6:52 PM |
| Terminations | Termination Effective Date | Insert | | | | 5/3/2012 6:52 PM |
| Terminations | Termination Reason | Insert | | | | 5/3/2012 6:52 PM |