Covered Entity Details

DSH320021AN PRESBYTERIAN HOSPITAL (Active) - information as of 4/25/2025 9:21:44 PM

Main Details

Name

PRESBYTERIAN HOSPITAL

Subdivision Name

Presbyterian Rust Medical Center Emergency Department

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH320021AN

Medicare Provider Number

320021

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

11/2/2012

Participating Start Date

1/1/2013

Participating Approval Date

11/8/2012

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

Presbyterian Healthcare Services
Erica Downing, VP, Pharmacy and Infusion Services & Chief Pharmacy Officer
(505) 724-8994

Primary Contact

Presbyterian Healthcare Services
Barbara Fried-Smith, 340B Program Coordinator
(505) 886-4820

Addresses

Street Address

2400 Unser Blvd SE
RIO RANCHO, NM 87124

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
03/20/2014: Termination recorded in error; site remained continuously eligible from participation start date.	03/31/2014

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

Presbyterian Rust Medical Center
2400 Unser Blvd SE
RIO RANCHO, NM 87124

Shipping Address 2

Presbyterian Pharmacy Services and Distribution Center
4580 Paradise Boulevard NW
Albuquerque, NM 87114

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH320021A	Child	DSH	PRESBYTERIAN HOSPITAL	PEDIATRIC SURGICAL GROUP	201 CEDAR SE	ALBUQUERQUE	NM	Active
DSH320021AA	Child	DSH	PRESBYTERIAN HOSPITAL	PMG KASEMAN GASTROENTEROLOGY	8300 CONSTITUTION NE, BLDG D	ALBUQUERQUE	NM	Terminated
DSH320021AB	Child	DSH	PRESBYTERIAN HOSPITAL	PMG NORTHSIDE PULMONARY	5901 HARPER DR NE	ALBUQUERQUE	NM	Active
DSH320021AC	Child	DSH	PRESBYTERIAN HOSPITAL	PMG KASEMAN ENDOCRINOLOGY	8300 CONSTITUTION AVE NE	ALBUQUERQUE	NM	Active
DSH320021AG	Child	DSH	PRESBYTERIAN HOSPITAL	Rust PMG Cardiology	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021AH	Child	DSH	PRESBYTERIAN HOSPITAL	Rust PMG OB/GYN	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021AJ	Child	DSH	PRESBYTERIAN HOSPITAL	Rust PMG Orthopedics	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021AK	Child	DSH	PRESBYTERIAN HOSPITAL	Rust PMG Podiatry	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021AL	Child	DSH	PRESBYTERIAN HOSPITAL	HIGH RESORT INFUSION CENTER	4100 HIGH RESORT BLVD	RIO RANCHO	NM	Active
DSH320021AM	Child	DSH	PRESBYTERIAN HOSPITAL	Rust PMG Oncology	2400 Unser Blvd	RIO RANCHO	NM	Active
DSH320021AN	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Rust Medical Center Emergency Department	2400 Unser Blvd SE	RIO RANCHO	NM	Active
DSH320021AP	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Pan American OB/GYN	6100 Pan American Freeway	Albuquerque	NM	Active
DSH320021AQ	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Cedar Pediatric Endocrinology	201 Cedar SE	Albuquerque	NM	Active
DSH320021AR	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Cedar Pediatric Pulmonary	201 Cedar SE	Albuquerque	NM	Active
DSH320021AS	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Cedar Neurosurgery	201 Cedar SE	Albuquerque	NM	Active
DSH320021AT	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Cedar Pediatric GI	201 Cedar SE	Albuquerque	NM	Active
DSH320021AU	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Cedar ENT	201 Cedar SE	Albuquerque	NM	Active
DSH320021AV	Child	DSH	PRESBYTERIAN HOSPITAL	PMG GI	1100 Lead Ave SE	Albuquerque	NM	Active
DSH320021AW	Child	DSH	PRESBYTERIAN HOSPITAL	Rust PMG Pulmonary	2400 Unser Blvd SE	Rio Rancho	NM	Terminated
DSH320021AX	Child	DSH	PRESBYTERIAN HOSPITAL	Rust PMG Surgery	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021AY	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Unser GI Clinic	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021AZ	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Northside-Wound Clinic	5901 Harper Dr NE	Albuquerque	NM	Active
DSH320021B	Child	DSH	PRESBYTERIAN HOSPITAL	PMG CEDAR CLINIC	201 CEDAR SE	ALBUQUERQUE	NM	Terminated
DSH320021BA	Child	DSH	PRESBYTERIAN HOSPITAL	PMG High Resort-Endocrinology	4100 High Resort Blvd	Rio Rancho	NM	Active
DSH320021BB	Child	DSH	PRESBYTERIAN HOSPITAL	PMG High Resort-Rheumatology	4100 High Resort Blvd	Rio Rancho	NM	Active
DSH320021BC	Child	DSH	PRESBYTERIAN HOSPITAL	PMG High Resort-Urgent Care	4100 High Resort Blvd	Rio Rancho	NM	Active
DSH320021BD	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Rio Rancho-Family Practice	4005 High Resort Blvd	Rio Rancho	NM	Active
DSH320021BE	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Rio Rancho Internal Medicine	4005 High Resort Blvd	Rio Rancho	NM	Active
DSH320021BF	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Rio Rancho Pediatrics	4005 High Resort Blvd	Rio Rancho	NM	Active
DSH320021BG	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Carmel-Cardiology	7920 Carmel Ave NE	Albuquerque	NM	Active
DSH320021BH	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Montgomery-Family Practice	8800 Montgomery Blvd NE	Albuquerque	NM	Active
DSH320021BJ	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Belen Urgent Care	609 S. Christopher	Belen	NM	Active
DSH320021BK	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Belen Family Practice	609 S. Christopher	Belen	NM	Active
DSH320021BL	Child	DSH	PRESBYTERIAN HOSPITAL	Las Estancias - Urgent Care	3630 Las Estancias Dr. SW	Albuquerque	NM	Active
DSH320021BM	Child	DSH	PRESBYTERIAN HOSPITAL	Las Estancias OB/GYN	3630 Las Estancias Dr SW	Albuquerque	NM	Active
DSH320021BN	Child	DSH	PRESBYTERIAN HOSPITAL	Las Estancias Family Practice	3630 Las Estancias Dr. SW	Albuquerque	NM	Active
DSH320021BP	Child	DSH	PRESBYTERIAN HOSPITAL	Las Estancias Internal Medicine	3630 Las Estancias Dr. SW	Albuquerque	NM	Terminated
DSH320021BQ	Child	DSH	PRESBYTERIAN HOSPITAL	Las Estancias Pediatrics	3630 Las Estancias Dr SW	Albuquerque	NM	Active
DSH320021BR	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Los Lunas-OB/GYN	200 Emilio Lopez Rd	Los Lunas	NM	Active
DSH320021BS	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Los Lunas-Family Practice	200 Emilio Lopez Rd	Los Lunas	NM	Active
DSH320021BT	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Pan American Neurology	6100 Pan American Freeway	Albuquerque	NM	Active
DSH320021BU	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Atrisco-Family Practice	3901 Atrisco NW	Albuquerque	NM	Active
DSH320021BV	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Atrisco-Urgent Care	3901 Atrisco NW	Albuquerque	NM	Active
DSH320021BW	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Pan American Pediatrics	6100 Pan American East Fwy NE	Albuquerque	NM	Active
DSH320021BX	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Northside-Family Practice	5901 Harper Dr NE	Albuquerque	NM	Terminated
DSH320021BY	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Pan American Podiatry	6100 Pan American Freeway NE	Albuquerque	NM	Terminated
DSH320021BZ	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Northside-Urgent Care	5901 Harper Dr NE	Albuquerque	NM	Active
DSH320021C	Child	DSH	PRESBYTERIAN HOSPITAL	PMG CEDAR OB/GYN	201 CEDAR SE	ALBUQUERQUE	NM	Active
DSH320021CA	Child	DSH	PRESBYTERIAN HOSPITAL	PMG San Mateo-Pediatrics	401 San Mateo SE	Albuquerque	NM	Active
DSH320021CB	Child	DSH	PRESBYTERIAN HOSPITAL	PMG San Mateo Internal Medicine	401 San Mateo SE	Albuquerque	NM	Active
DSH320021CC	Child	DSH	PRESBYTERIAN HOSPITAL	PMG San Mateo-Family Practice	401 San Mateo SE	Albuquerque	NM	Active
DSH320021CD	Child	DSH	PRESBYTERIAN HOSPITAL	PMG San Mateo-OB/GYN	401 San Mateo SE	Albuquerque	NM	Terminated
DSH320021CE	Child	DSH	PRESBYTERIAN HOSPITAL	PMG High Resort-Pain & Spine	4100 High Resort Blvd	Rio Rancho	NM	Active
DSH320021CF	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Unser GI Lab	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021CG	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Pediatric Hematology/Oncology	201 Cedar St SE	Albuquerque	NM	Active
DSH320021CH	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Pediatric Chronic Care	201 Cedar St SE	Albuquerque	NM	Active
DSH320021CJ	Child	DSH	PRESBYTERIAN HOSPITAL	Rust PMG Urology	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021CK	Child	DSH	PRESBYTERIAN HOSPITAL	PMG 528 Family Practice	3777 NM Highway 528 NE	Rio Rancho	NM	Active
DSH320021CL	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Carmel Urgent Care	5500 Balloon Fiesta Pkwy	Albuquerque	NM	Terminated
DSH320021CM	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Alameda Urgent Care	1648 Alameda Blvd NW	Albuquerque	NM	Terminated
DSH320021CN	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Kaseman Orthopedics	8300 Constitution Ave NE	Albuquerque	NM	Active
DSH320021CP	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Outpatient Gastroenterology Lab	301 Cedar St SE	Albuquerque	NM	Active
DSH320021CQ	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Heart Group - Belen Cardiology	609 S Christopher	Belen	NM	Terminated
DSH320021CR	Child	DSH	PRESBYTERIAN HOSPITAL	PMG High Resort Sleep Disorder Center	4100 High Resort Blvd	Rio Rancho	NM	Active
DSH320021CS	Child	DSH	PRESBYTERIAN HOSPITAL	Rust Medical Center-Presbyterian Heart Group	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021CT	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Cedar Pediatric Neurology	201 Cedar SE	Albuquerque	NM	Active
DSH320021CU	Child	DSH	PRESBYTERIAN HOSPITAL	Rust Medical Center-Surgical Services	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021CV	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Kaseman Hospital Cardiovascular Lab-NON-INVASIVE	8300 Constitution NE	Albuquerque	NM	Active
DSH320021CX	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Rio Rancho Internal Medicine RX	4005 High Resort Blvd	Rio Rancho	NM	Active
DSH320021CY	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Kaseman Podiatry	8300 Constitution Ave NE	Albuquerque	NM	Active
DSH320021CZ	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Child & Adolescent Behavioral Health	8312 Kaseman Court NE	Albuquerque	NM	Active
DSH320021D	Child	DSH	PRESBYTERIAN HOSPITAL	PMG SURGERY CEDAR	201 CEDAR SE	ALBUQUERQUE	NM	Active
DSH320021DA	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Heart Group - Presbyteran Medical Group Kaseman Cardiology	8300 Constitution NE	Albquerque	NM	Terminated
DSH320021DB	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Kaseman Hospital Intensive Outpatient Therapy Program	8300 Constitution NE	Albuquerque	NM	Terminated
DSH320021DC	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Belen Internal Medicine	609 S Christopher	Belen	NM	Active
DSH320021DD	Child	DSH	PRESBYTERIAN HOSPITAL	Rust Medical Center Cardiovascular Lab Invasive	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021DE	Child	DSH	PRESBYTERIAN HOSPITAL	Rust Medical Center - Gastrointestinal Lab	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021DF	Child	DSH	PRESBYTERIAN HOSPITAL	Rust Medical Center - Cardiovascular Lab Non-Invasive	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021DG	Child	DSH	PRESBYTERIAN HOSPITAL	Rust Medical Center - Pulmonary	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021DH	Child	DSH	PRESBYTERIAN HOSPITAL	Rust Medical Center - Family Birth Center	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021DJ	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Kaseman Hospital Psychiatric Assessment and Referral Adult Treatment Unit	8300 Constitution NE	Albuquerque	NM	Active
DSH320021DK	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Kaseman Hospital Pulmonary	8300 Constitution Ave NE	Albuquerque	NM	Active
DSH320021DL	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Rust Neurology	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021DM	Child	DSH	PRESBYTERIAN HOSPITAL	The Bariatric Center at Presbyterian Rust Medical Center	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021DN	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Pan American Family Practice	6100 Pan American East Fwy NE	Albuquerque	NM	Active
DSH320021DP	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group 528 Internal Medicine	3777 New Mexico Highway 528 NE	Rio Rancho	NM	Active
DSH320021DQ	Child	DSH	PRESBYTERIAN HOSPITAL	PMG 528 / Pediatrics	3777 NM HIGHWAY 528 NE	RIO RANCHO	NM	Terminated
DSH320021DR	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Cedar Transplant Surgery	201 Cedar SE	Albuquerque	NM	Active
DSH320021DS	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Kaseman Breast Surgical Oncology	8300 Constitution Ave NE	Albuquerque	NM	Active
DSH320021DT	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Unser Ear, Nose, and Throat	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021DU	Child	DSH	PRESBYTERIAN HOSPITAL	Rio Rancho Peds Psych	4005 High Resort Blvd SE	Rio Rancho	NM	Active
DSH320021DV	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Cedar Pediatric Ear, Nose, and Throat	201 Cedar Street SE	Albuquerque	NM	Active
DSH320021DW	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Infusion Center - Infusion	201 Cedar SE, Suite 4620	Albuquerque	NM	Active
DSH320021DX	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Paradise Urgent Care - Urgent Care	4588 Paradise NW	Albuquerque	NM	Terminated
DSH320021DY	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Paradise Family Practice - Family Practice	4588 Paradise NW	Albuquerque	NM	Active
DSH320021DZ	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Rust Breast Surgical Oncology - Surgical Oncology	2400 Unser Boulevard SE	Rio Rancho	NM	Active
DSH320021E	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN HEART GROUP	201 CEDAR SE	ALBUQUERQUE	NM	Active
DSH320021EA	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Cedar Pediatric Behavioral	201 Cedar Street Southeast	Albuquerque	NM	Active
DSH320021EB	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Belen Pediatrics	609 South Christopher	Belen	NM	Active
DSH320021EC	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Montgomery Internal Medicine	8800 Montgomery Blvd NE	Albuquerque	NM	Active
DSH320021ED	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group High Resort Pediatric Urgent Care	4100 High Resort Boulevard	Rio Rancho	NM	Terminated
DSH320021EF	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Medical Group Kaseman Behavioral Recovery Medicine	8312 Kaseman Court Northeast	Albuquerque	NM	Active
DSH320021EG	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN KASEMAN INTERVENTIONAL RADIOLOGY	8300 Constitution NE	Albuquerque	NM	Active
DSH320021EH	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN MEDICAL GROUP CEDAR SURGICAL ONCOLOGY - CEDAR SURGICAL ONCOLOGY	201 Cedar SE	Albuquerque	NM	Terminated
DSH320021EJ	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN KASEMAN RADIATION ONCOLOGY	8300 Constitution NE	Albuquerque	NM	Active
DSH320021EK	Child	DSH	PRESBYTERIAN HOSPITAL	RUST MEDICAL CENTER INTERVENTIONAL RADIOLOGY	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021EL	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN RUST MEDICAL CENTER RADIATION ONCOLOGY	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021EM	Child	DSH	PRESBYTERIAN HOSPITAL	CEDAR UROLOGY	201 Cedar SE	ALBUQUERQUE	NM	Active
DSH320021EN	Child	DSH	PRESBYTERIAN HOSPITAL	COMPLETE CARE CLINIC	8100 Constitution Place	ALBUQUERQUE	NM	Active
DSH320021EP	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Cedar Neuro Intervention - Neurology	201 Cedar SE	ALBUQUERQUE	NM	Terminated
DSH320021EQ	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Heart Group Cardiac Surgery	201 Cedar SE	ALBUQUERQUE	NM	Active
DSH320021ER	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Vascular - Vascular	201 Cedar SE	ALBUQUERQUE	NM	Active
DSH320021ES	Child	DSH	PRESBYTERIAN HOSPITAL	Las Estancias Pediatric Urgent Care	3630 Las Estancias Dr SW	ALBUQUERQUE	NM	Active
DSH320021ET	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Paseo 24/7 ED UC	6400 Paseo Del Norte NE	ALBUQUERQUE	NM	Active
DSH320021EU	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Carmel Pediatric Urgent Care - Ped UC	7920 Carmel Ave NE	ALBUQUERQUE	NM	Terminated
DSH320021EV	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Coors 24/7 ED UC	4515 Coors Blvd NW	ALBUQUERQUE	NM	Active
DSH320021EW	Child	DSH	PRESBYTERIAN HOSPITAL	Pan American Oral and Maxillofacial - Dental Surgery	6100 Pan American East Fwy NE	Albuquerque	NM	Active
DSH320021EX	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Unser Gyn Oncology	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021EY	Child	DSH	PRESBYTERIAN HOSPITAL	PMG High Resort - Oncology	4100 High Resort Blvd.	Rio Rancho	NM	Terminated
DSH320021EZ	Child	DSH	PRESBYTERIAN HOSPITAL	PH Covid Infusion	201 Cedar SE	Albuquerque	NM	Active
DSH320021FA	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Carmel Pediatric Cardiology	7920 Carmel Ave NE	Albuquerque	NM	Active
DSH320021FB	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Northside Pediatric Urgent Care	5901 Harper Dr. NE	Albuquerque	NM	Active
DSH320021FC	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Pan American Urogynecology	6100 Pan American Freeway NE	Albuquerque	NM	Active
DSH320021FD	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Gastrointestinal Lab - GI Lab	1001 Silver Ave SE	Albuquerque	NM	Active
DSH320021FE	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Heart Group - Pediatric Cardiology	201 Cedar St SE, Suite 700	Albuquerque	NM	Active
DSH320021FF	Child	DSH	PRESBYTERIAN HOSPITAL	Rust Medical Center - Nuclear Medicine - Nuclear Medicine	2400 Unser Blvd SE	Rio Rancho	NM	Active
DSH320021FG	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Kaseman Hospital PET Scan	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021FH	Child	DSH	PRESBYTERIAN HOSPITAL	Presbyterian Isleta 24/7 ED UC - Emergency Dept/Urgent Care	3436 ISLETA BLVD SW	Albuquerque	NM	Active
DSH320021FJ	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Kaseman Endo Pharmacist - ENDOCRINOLOGY	8300 CONSTITUTION AVE NE	ALBUQUERQUE	NM	Active
DSH320021FK	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN KASEMAN NUCLEAR MEDICINE - NUCLEAR MEDICINE	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021FL	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN KASEMAN CT SCAN - CT SCAN	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021FM	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN KASEMAN MRI - MRI	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021J	Child	DSH	PRESBYTERIAN HOSPITAL	PMG KASEMAN ADULT HEALTHCARE	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021K	Child	DSH	PRESBYTERIAN HOSPITAL	PMG KASEMAN RHEUMATOLOGY	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021L	Child	DSH	PRESBYTERIAN HOSPITAL	PMG KASEMAN BEHAVIORAL MEDICINE	1325 WYOMING BLVD NE	ALBUQUERQUE	NM	Active
DSH320021M	Child	DSH	PRESBYTERIAN HOSPITAL	PMG KASEMAN FAMILY HEALTHCARE	8300 CONSTITUTION AVE NE	ALBUQUERQUE	NM	Active
DSH320021R	Child	DSH	PRESBYTERIAN HOSPITAL	PMG SURGERY KASEMAN	8300 CONSTITUTION AVE NE	ALBUQUERQUE	NM	Active
DSH320021T	Child	DSH	PRESBYTERIAN HOSPITAL	PMG Wyoming Family Practice	5550 WYOMING BLVD NE	ALBUQUERQUE	NM	Active
DSH320021U	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN KASEMAN HOSPITAL EMERGENCY DEPT	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021V	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN KASEMAN HOSPITAL DAY SURGERY	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021W	Child	DSH	PRESBYTERIAN HOSPITAL	PMG KASEMAN PAIN AND SPINE	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active
DSH320021X	Child	DSH	PRESBYTERIAN HOSPITAL	PRESBYTERIAN KASEMAN HOSPITAL CANCER TREATMENT CENTER	8300 CONSTITUTION AVE NE	ALBUQUERQUE	NM	Active
DSH320021Y	Child	DSH	PRESBYTERIAN HOSPITAL	PMG KASEMAN SLEEP DISORDER CENTER	8300 CONSTITUTION NE	ALBUQUERQUE	NM	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 1:01:12 PM	9/6/2024 2:38:03 PM	9/6/2024 2:38 PM
Contacts	Primary Contact	Update	Group Change Request	Shreve, Patrick 340B Analyst III Presbyterian Healthcare Services 5057247192	Fried-Smith, Barbara 340B Program Coordinator Presbyterian Healthcare Services 5058864820	7/31/2024 11:23 AM
Contacts	Primary Contact	Update	Group Change Request	Green, Kelly 340B Program Manager Presbyterian Healthcare Services 5057247761	Shreve, Patrick 340B Analyst III Presbyterian Healthcare Services 5057247192	3/18/2024 7:11 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 12:25:09 PM	9/6/2023 1:01:12 PM	9/6/2023 1:01 PM
Addresses	Shipping Address	Insert	Recertification		Presbyterian Rust Medical Center 2400 Unser Blvd SE RIO RANCHO, NM 87124	9/16/2022 12:25 PM
Addresses	Shipping Address	Insert	Recertification		Presbyterian Pharmacy Services and Distribution Center 4580 Paradise Boulevard NW Albuquerque, NM 87114	9/16/2022 12:25 PM
Details	Last Recertification Date	Update	Recertification	9/13/2021 9:59:01 AM	9/16/2022 12:25:09 PM	9/16/2022 12:25 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00109 (NM)		7/15/2022 11:31 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1104802354 (NM)		7/15/2022 11:31 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1215913470 (NM)		7/15/2022 11:31 AM
Contacts	Authorizing Official	Update	Change Request	Graham, David Scott VP-PDS Clinical Support Srvc Presbyterian Healthcare Services 5058411872	Downing, Erica VP, Pharmacy and Infusion Services & Chief Pharmacy Officer Presbyterian Healthcare Services 5057248994	3/3/2022 12:08 PM
Details	Last Recertification Date	Update	Recertification	9/14/2020 2:46:37 PM	9/13/2021 9:59:01 AM	9/13/2021 9:59 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1215913470 ( )		9/14/2020 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1104802354	9/14/2020 2:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/14/2020 2:46 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1215913470	9/14/2020 2:46 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/14/2020 2:46 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1104802354 ( )		9/14/2020 2:46 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 2:44:20 PM	9/14/2020 2:46:37 PM	9/14/2020 2:46 PM
Contacts	Authorizing Official	Update	Change Request	Larsen, Roger Sr. Vice President and Chief Financial Officer Presbyterian Healthcare Services 5059235338	Graham, David Scott VP-PDS Clinical Support Srvc Presbyterian Healthcare Services 5058411872	2/18/2020 8:17 AM
Details	Last Recertification Date	Update	Recertification	8/27/2018 2:05:35 PM	8/21/2019 2:44:20 PM	8/21/2019 2:44 PM
Contacts	Primary Contact	Update	Change Request	Knight, Lauris 340B Program Coordinator Presbyterian Healthcare Services 5057248028	Green, Kelly 340B Program Manager Presbyterian Healthcare Services 5057247761	4/16/2019 9:28 AM
Contacts	Authorizing Official	Update	Change Request	Podley, Sandra C. VP Operations PDS Presbyterian Healthcare Services 5059235364	Larsen, Roger Sr. Vice President and Chief Financial Officer Presbyterian Healthcare Services 5059235338	4/1/2019 8:46 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 12:50:17 PM	8/27/2018 2:05:35 PM	8/27/2018 2:05 PM
Details	Last Recertification Date	Update	Recertification	8/26/2016 12:00:00 AM	11/9/2017 12:50:17 PM	11/9/2017 12:50 PM
Contacts	Authorizing Official	Update	New Registration	Podley, Sandra C. VP Operations PDS 5059235364	Podley, Sandra C. VP Operations PDS Presbyterian Healthcare Services 5059235364	10/6/2017 11:54 AM
Contacts	Primary Contact	Update		Knight, Lauris 340B Program Coordinator 5057248028	Knight, Lauris 340B Program Coordinator Presbyterian Healthcare Services 5057248028	9/22/2017 4:11 PM
Contacts	Primary Contact	Update		Matlock, Sara Pharmacy Business Associate 5057248981	Knight, Lauris 340B Program Coordinator 5057248028	7/25/2017 11:13 AM
Contacts	Authorizing Official	Insert			Podley, Sandra C. VP Operations PDS 5059235364	7/25/2017 11:13 AM
Contacts	Signed By	Insert			MAXWELL, DALE SENIOR VP & CFO 5059235353	7/25/2017 11:13 AM
Addresses	Main Address	Insert			2400 Unser Blvd SE RIO RANCHO, NM 87124	7/25/2017 11:13 AM
Contacts	Primary Contact	Insert			Matlock, Sara Pharmacy Business Associate 5057248981	1/17/2017 9:43 AM
Medicaid Billing	NPI: Number	Insert			1104802354	8/26/2016 9:51 AM
Details	Last Recertification Date	Update		8/27/2015 12:00:00 AM	8/26/2016 12:00:00 AM	8/26/2016 9:51 AM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	8/27/2015 12:00:00 AM	8/27/2015 4:39 PM
Medicaid Billing	NPI: Number	Insert			1215913470	7/29/2015 6:42 PM
Details	Last Recertification Date	Update		9/9/2013 9:40:20 PM	9/3/2014 12:00:00 AM	9/3/2014 1:30 PM
Details	State	Update		Terminated	Active	3/31/2014 12:59 PM
Terminations	Termination Date	Update		4/1/2014 12:00:00 AM		3/31/2014 12:59 PM
Terminations	Termination Reason	Update		Site closure		3/31/2014 12:59 PM
Details	Comments Public	Insert			03/20/2014: Termination recorded in error; site remained continuously eligible from participation start date.	3/31/2014 12:59 PM
Details	State	Update		Active	Terminated	3/20/2014 7:37 AM
Terminations	Termination Date	Update			4/1/2014 12:00:00 AM	3/20/2014 7:37 AM
Terminations	Termination Reason	Update			Site closure	3/20/2014 7:37 AM
Details	Last Recertification Date	Update			9/9/2013 9:40:20 PM	9/9/2013 9:40 PM
Details	340B ID	Update		IS-AP-DSH320021AN	DSH320021AN	11/8/2012 4:47 PM
Dates	Participating Approval Date	Update			11/8/2012 12:00:00 AM	11/8/2012 4:47 PM
Details	State	Update		Pending	Active	11/8/2012 4:47 PM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	11/8/2012 4:47 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-AP-DSH320021AN	11/5/2012 8:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	11/2/2012 3:59 PM
Medicaid Billing	Medicaid: Number	Insert			00109	11/2/2012 3:59 PM
Medicaid Billing	Medicaid: State	Insert			NM	11/2/2012 3:59 PM
Details	Last Recertification Date	Insert				11/2/2012 3:59 PM
Details	Grant Number	Insert				11/2/2012 3:59 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	11/2/2012 3:59 PM
Details	Is Authorizing Official EHB Data	Insert				11/2/2012 3:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert				11/2/2012 3:59 PM
Details	Medicare Provider Number	Insert			320021	11/2/2012 3:59 PM
Details	Entity Name	Insert			PRESBYTERIAN HOSPITAL	11/2/2012 3:59 PM
Details	Program Code	Insert			DSH	11/2/2012 3:59 PM
Details	Entity Subname	Insert			Presbyterian Rust Medical Center Emergency Department	11/2/2012 3:59 PM
Dates	Participating Approval Date	Insert				11/2/2012 3:59 PM
Details	State	Insert			Pending	11/2/2012 3:59 PM
Dates	Registration Date	Insert			11/2/2012 12:00:00 AM	11/2/2012 3:59 PM
Dates	Signed By Date	Insert			11/2/2012 12:00:00 AM	11/2/2012 3:59 PM
Dates	Start Date	Insert				11/2/2012 3:59 PM
Terminations	Termination Comments	Insert				11/2/2012 3:59 PM
Terminations	Termination Date	Insert				11/2/2012 3:59 PM
Terminations	Termination Effective Date	Insert				11/2/2012 3:59 PM
Terminations	Termination Reason	Insert				11/2/2012 3:59 PM