| Details | Last Recertification Date | Update | Recertification | 8/16/2023 11:27:09 AM | 8/16/2024 11:56:55 AM | 8/16/2024 11:56 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 7:13:24 PM | 8/16/2023 11:27:09 AM | 8/16/2023 11:27 AM |
| Contacts | Primary Contact | Update | Group Change Request | MenMuir, Kerry
Director of Inpatient Pharmacy
Ronald Reagan UCLA Medical Center
3102678509 | Balderrama, Lana
340B Program Supervisor
UCLA
3102671278 | 5/16/2023 12:31 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2021 10:40:49 AM | 9/8/2022 7:13:24 PM | 9/8/2022 7:13 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Staton, Paul
CFO
UCLA Medical Center
3102679308 | Wallace, Tammy
Chief Financial Officer Hospital System
UCLA Health
3107948627 | 6/21/2022 7:18 AM |
| Addresses | Billing Address | Update | Change Request | Santa Monica UCLA Medical Center
File 82278
Los Angeles, CA 90074 | Santa Monica UCLA Medical Center
1250 16th Street
Santa Monica, CA 90404 | 11/1/2021 12:10 PM |
| Addresses | Shipping Address | Delete | Recertification | Santa Monica UCLAMC and Orthopaedic Hospital
1250 16th Street, Room B470
Santa Monica, CA 90404 | | 8/30/2021 10:40 AM |
| Addresses | Shipping Address | Insert | Recertification | | Santa Monica UCLAMC and Orthopaedic Hospital
1250 16th Street, Room B490
Santa Monica, CA 90404 | 8/30/2021 10:40 AM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2020 1:05:06 PM | 8/30/2021 10:40:49 AM | 8/30/2021 10:40 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 8/18/2020 1:05 PM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2019 12:03:44 PM | 8/18/2020 1:05:06 PM | 8/18/2020 1:05 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Men Muir, Kerry
Director of Inpatient Pharmacy
Ronald Reagan UCLA Medical Center
3102678509 | MenMuir, Kerry
Director of Inpatient Pharmacy
Ronald Reagan UCLA Medical Center
3102678509 | 12/5/2019 4:45 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Men Muir, Kerry
Interim Chief of Pharmacy
Ronald Reagan UCLA Medical Center
3102678509 | Men Muir, Kerry
Director of Inpatient Pharmacy
Ronald Reagan UCLA Medical Center
3102678509 | 12/4/2019 2:31 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2018 10:51:15 AM | 8/21/2019 12:03:44 PM | 8/21/2019 12:03 PM |
| Details | Last Recertification Date | Update | Recertification | 11/13/2017 10:31:03 AM | 8/16/2018 10:51:15 AM | 8/16/2018 10:51 AM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2016 12:00:00 AM | 11/13/2017 10:31:03 AM | 11/13/2017 10:31 AM |
| Contacts | Primary Contact | Insert | Change Request | | Men Muir, Kerry
Interim Chief of Pharmacy
Ronald Reagan UCLA Medical Center
3102678509 | 10/16/2017 12:16 PM |
| Contacts | Authorizing Official | Update | | Staton, Paul
CFO
3102679308 | Staton, Paul
CFO
UCLA Medical Center
3102679308 | 10/10/2017 5:41 PM |
| Contacts | Signed By | Update | | Staton, Paul
CFO
3102679308 | Staton, Paul
CFO
UCLA Medical Center
3102679308 | 10/10/2017 5:41 PM |
| Contacts | Authorizing Official | Insert | | | Staton, Paul
CFO
3102679308 | 4/26/2017 10:13 AM |
| Contacts | Signed By | Insert | | | Staton, Paul
CFO
3102679308 | 4/26/2017 10:13 AM |
| Addresses | Main Address | Insert | | |
1245 16th Street, Suite 225
Santa Monica, CA 90404 | 9/1/2016 8:47 AM |
| Addresses | Billing Address | Insert | | | Santa Monica UCLA Medical Center
File 82278
Los Angeles, CA 90074 | 9/1/2016 8:47 AM |
| Addresses | Shipping Address | Insert | | | Santa Monica UCLAMC and Orthopaedic Hospital
1250 16th Street, Room B470
Santa Monica, CA 90404 | 9/1/2016 8:47 AM |
| Details | Last Recertification Date | Update | | 9/1/2015 12:00:00 AM | 9/1/2016 12:00:00 AM | 9/1/2016 8:47 AM |
| Details | Last Recertification Date | Update | | 8/26/2014 12:00:00 AM | 9/1/2015 12:00:00 AM | 9/2/2015 2:26 PM |
| Details | Last Recertification Date | Update | | 9/10/2013 6:23:40 PM | 8/26/2014 12:00:00 AM | 8/26/2014 8:50 PM |
| Details | Last Recertification Date | Update | | | 9/10/2013 6:23:40 PM | 9/10/2013 6:23 PM |
| Details | 340B ID | Update | | IS-DSH050112A-JM051512G | DSH050112A | 6/27/2012 8:05 AM |
| Dates | Participating Approval Date | Update | | | 6/27/2012 12:00:00 AM | 6/27/2012 8:05 AM |
| Details | State | Update | | Pending | Active | 6/27/2012 8:05 AM |
| Dates | Start Date | Update | | | 7/1/2012 12:00:00 AM | 6/27/2012 8:05 AM |
| Details | 340B ID | Update | | JM051512G | IS-DSH050112A-JM051512G | 6/3/2012 12:44 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | JM051512G | 5/15/2012 7:06 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 5/15/2012 3:30 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | HSC30112W | 5/15/2012 3:30 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 5/15/2012 3:30 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1427055839 | 5/15/2012 3:30 PM |
| Details | Last Recertification Date | Insert | | | | 5/15/2012 3:30 PM |
| Details | Grant Number | Insert | | | | 5/15/2012 3:30 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 5/15/2012 3:30 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 5/15/2012 3:30 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 5/15/2012 3:30 PM |
| Details | Medicare Provider Number | Insert | | | 050112 | 5/15/2012 3:30 PM |
| Details | Entity Name | Insert | | | SANTA MONICA UCLAMC AND ORTHOPAEDIC HOSPITAL | 5/15/2012 3:30 PM |
| Details | Program Code | Insert | | | DSH | 5/15/2012 3:30 PM |
| Details | Entity Subname | Insert | | | Pain Management Center | 5/15/2012 3:30 PM |
| Dates | Participating Approval Date | Insert | | | | 5/15/2012 3:30 PM |
| Details | State | Insert | | | Pending | 5/15/2012 3:30 PM |
| Dates | Registration Date | Insert | | | 5/15/2012 12:00:00 AM | 5/15/2012 3:30 PM |
| Dates | Signed By Date | Insert | | | 5/15/2012 12:00:00 AM | 5/15/2012 3:30 PM |
| Dates | Start Date | Insert | | | | 5/15/2012 3:30 PM |
| Terminations | Termination Comments | Insert | | | | 5/15/2012 3:30 PM |
| Terminations | Termination Date | Insert | | | | 5/15/2012 3:30 PM |
| Terminations | Termination Effective Date | Insert | | | | 5/15/2012 3:30 PM |
| Terminations | Termination Reason | Insert | | | | 5/15/2012 3:30 PM |