| Contacts | Authorizing Official | Update | Change Request | Tanas, Majid
VP Pharmacy Services
Legacy Health
5034155011 | Kelly, Kecia
SVP Chief Nursing Officer
Legacy Health
5034155199 | 9/12/2024 11:17 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2023 9:00:57 AM | 9/2/2024 10:41:25 AM | 9/2/2024 10:41 AM |
| Addresses | Shipping Address | Insert | Recertification | | LEGACY EMANUEL MEDICAL CENTER
2801 N Gantenbein Ave
Portland, OR 97227 | 9/8/2023 9:00 AM |
| Addresses | Billing Address | Update | Recertification | LEGACY EMANUEL MEDICAL CENTER
2801 N. Gantenbein
Portland, OR 97227 | LEGACY EMANUEL MEDICAL CENTER
2801 N Gantenbein Ave
Portland, OR 97227 | 9/8/2023 9:00 AM |
| Addresses | Shipping Address | Delete | Recertification | LEGACY EMANUEL MEDICAL CENTER
2801 N. Gantenbein
Portland, OR 97227 | | 9/8/2023 9:00 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 1:54:26 PM | 9/8/2023 9:00:57 AM | 9/8/2023 9:00 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2021 6:54:56 PM | 9/8/2022 1:54:26 PM | 9/8/2022 1:54 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:48 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 055103 | 6/13/2022 6:48 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OR | 6/13/2022 6:48 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:48 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 055330 | 6/13/2022 6:48 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OR | 6/13/2022 6:48 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:48 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1019958 | 6/13/2022 6:48 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | WA | 6/13/2022 6:48 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1831112358 | 6/13/2022 6:48 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | OR | 6/13/2022 6:48 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1831112358 | 6/13/2022 6:48 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | WA | 6/13/2022 6:48 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2020 9:31:58 AM | 9/9/2021 6:54:56 PM | 9/9/2021 6:54 PM |
| Contacts | Authorizing Official | Update | Change Request | Loomis, Anna
SVP Chief Financial Officer
Legacy Health
5034155730 | Tanas, Majid
VP Pharmacy Services
Legacy Health
5034155011 | 1/11/2021 8:00 AM |
| Addresses | Main Address | Update | Recertification |
3001 N. Gantenbein Ave.
Portland, OR 97227 |
3001 N Gantenbein Ave
Portland, OR 97227 | 9/8/2020 9:31 AM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2019 5:13:42 PM | 9/8/2020 9:31:58 AM | 9/8/2020 9:31 AM |
| Details | Entity Subname | Update | Recertification | Legacy Emanuel Chronic Wound and Outpatient Burn Clinic | Legacy Emanuel Wound Care Center / Chronic Wound Care Center 150-2165 | 9/8/2020 9:31 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034137764 | Valcarlos, Elena
Pharmacy Systems Manager
Legacy Health
5034137764 | 1/31/2020 4:08 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034131321 | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034137764 | 1/31/2020 4:08 PM |
| Contacts | Authorizing Official | Update | Change Request | Bradley, Carol
SVP and Chief Nursing Officer
Legacy Health
5034155199 | Loomis, Anna
SVP Chief Financial Officer
Legacy Health
5034155730 | 9/16/2019 5:17 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2018 5:52:58 PM | 9/6/2019 5:13:42 PM | 9/6/2019 5:13 PM |
| Contacts | Primary Contact | Update | Change Request | Stoner, Kathleen C.
Vice President Supply Chain and Pharmacy Services
Legacy Health
5039444276 | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034131321 | 8/8/2019 7:36 AM |
| Contacts | Authorizing Official | Update | Change Request | Newcomb III, Everett W.
Sr Vice President and COO
Legacy Health
5034155252 | Bradley, Carol
SVP and Chief Nursing Officer
Legacy Health
5034155199 | 12/19/2018 12:49 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Stoner, Kathleen C.
Director, LH Pharmacy Services
Legacy Health
5034136926 | Stoner, Kathleen C.
Vice President Supply Chain and Pharmacy Services
Legacy Health
5039444276 | 9/7/2018 1:25 PM |
| Details | Last Recertification Date | Update | Recertification | 11/22/2017 10:17:08 AM | 8/21/2018 5:52:58 PM | 8/21/2018 5:52 PM |
| Details | Entity Name | Update | Recertification | LEGACY EMANUEL MEDICAL CENTER | LEGACY EMANUEL HOSPITAL & HEALTH CENTER | 11/29/2017 8:38 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2016 12:00:00 AM | 11/22/2017 10:17:08 AM | 11/22/2017 10:17 AM |
| Contacts | Authorizing Official | Update | | Newcomb III, Everett W.
Sr Vice President and COO
5034155252 | Newcomb III, Everett W.
Sr Vice President and COO
Legacy Health
5034155252 | 10/11/2017 1:31 PM |
| Contacts | Primary Contact | Update | | Stoner, Kathleen C.
Director, LH Pharmacy Services
5034136926 | Stoner, Kathleen C.
Director, LH Pharmacy Services
Legacy Health
5034136926 | 10/11/2017 12:40 PM |
| Contacts | Primary Contact | Insert | | | Stoner, Kathleen C.
Director, LH Pharmacy Services
5034136926 | 6/12/2017 2:32 PM |
| Contacts | Authorizing Official | Insert | | | Newcomb III, Everett W.
Sr Vice President and COO
5034155252 | 6/12/2017 2:32 PM |
| Contacts | Signed By | Insert | | | Eager, David E.
Sr. VP and CFO, Legacy Health
5034155730 | 6/12/2017 2:32 PM |
| Addresses | Main Address | Insert | | |
3001 N. Gantenbein Ave.
Portland, OR 97227 | 10/26/2016 6:02 PM |
| Addresses | Billing Address | Insert | | | LEGACY EMANUEL MEDICAL CENTER
2801 N. Gantenbein
Portland, OR 97227 | 10/26/2016 6:02 PM |
| Addresses | Shipping Address | Insert | | | LEGACY EMANUEL MEDICAL CENTER
2801 N. Gantenbein
Portland, OR 97227 | 10/26/2016 6:02 PM |
| Details | Last Recertification Date | Update | | 9/1/2015 12:00:00 AM | 8/31/2016 12:00:00 AM | 8/31/2016 6:01 PM |
| Details | Entity Subname | Update | | Legacy Emanuel Wound Care Center and Bone Clinic | Legacy Emanuel Chronic Wound and Outpatient Burn Clinic | 6/29/2016 9:48 AM |
| Details | Last Recertification Date | Update | | 8/27/2014 12:00:00 AM | 9/1/2015 12:00:00 AM | 9/1/2015 6:13 PM |
| Details | Last Recertification Date | Update | | 9/9/2013 9:32:39 PM | 8/27/2014 12:00:00 AM | 8/27/2014 11:24 AM |
| Details | Last Recertification Date | Update | | | 9/9/2013 9:32:39 PM | 9/9/2013 9:32 PM |
| Details | 340B ID | Update | | IS-DR-DSH380007E | DSH380007E | 9/19/2012 3:57 PM |
| Dates | Participating Approval Date | Update | | | 9/19/2012 12:00:00 AM | 9/19/2012 3:57 PM |
| Details | State | Update | | Pending | Active | 9/19/2012 3:57 PM |
| Dates | Start Date | Update | | | 10/1/2012 12:00:00 AM | 9/19/2012 3:57 PM |
| Details | Entity Subname | Update | | Legacy Emanuel Wound Care Center | Legacy Emanuel Wound Care Center and Bone Clinic | 9/14/2012 1:32 PM |
| Details | 340B ID | Update | | DR-DSH380007F | IS-DR-DSH380007E | 9/14/2012 1:31 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | DR-DSH380007F | 9/6/2012 3:04 PM |
| Details | Last Recertification Date | Insert | | | | 8/28/2012 4:53 PM |
| Details | Grant Number | Insert | | | | 8/28/2012 4:53 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 8/28/2012 4:53 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 8/28/2012 4:53 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 8/28/2012 4:53 PM |
| Details | Medicare Provider Number | Insert | | | 380007 | 8/28/2012 4:53 PM |
| Details | Entity Name | Insert | | | LEGACY EMANUEL MEDICAL CENTER | 8/28/2012 4:53 PM |
| Details | Program Code | Insert | | | DSH | 8/28/2012 4:53 PM |
| Details | Entity Subname | Insert | | | Legacy Emanuel Wound Care Center | 8/28/2012 4:53 PM |
| Dates | Participating Approval Date | Insert | | | | 8/28/2012 4:53 PM |
| Details | State | Insert | | | Pending | 8/28/2012 4:53 PM |
| Dates | Registration Date | Insert | | | 8/28/2012 12:00:00 AM | 8/28/2012 4:53 PM |
| Dates | Signed By Date | Insert | | | 8/28/2012 12:00:00 AM | 8/28/2012 4:53 PM |
| Dates | Start Date | Insert | | | | 8/28/2012 4:53 PM |
| Terminations | Termination Comments | Insert | | | | 8/28/2012 4:53 PM |
| Terminations | Termination Date | Insert | | | | 8/28/2012 4:53 PM |
| Terminations | Termination Effective Date | Insert | | | | 8/28/2012 4:53 PM |
| Terminations | Termination Reason | Insert | | | | 8/28/2012 4:53 PM |