| Contacts | Authorizing Official | Update | Change Request | Pilgrim, Patti
Chief Financial Officer
MemorialCare Long beach medical Center/Miller children's & Women's Hospital
5629331905 | Kent, Blair
Chief Executive Officer
Long Beach Medical Center
5629331111 | 12/12/2024 12:51 PM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2023 1:19:45 PM | 8/16/2024 12:10:40 PM | 8/16/2024 12:10 PM |
| Addresses | Billing Address | Insert | Change Request | | Long Beach Memorial Medical Center, Inc., dba MemorialCare Miller Children's and Women's Hospital LB
PO Box 20892
Fountain Valley, CA 92728 | 6/13/2024 2:46 PM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2022 5:54:54 PM | 8/21/2023 1:19:45 PM | 8/21/2023 1:19 PM |
| Contacts | Authorizing Official | Update | Change Request | Katz, Yair
Chief Executive MCWH SVP Peds
MemorialCare Miller Children's and Women's Hospital
5629338008 | Pilgrim, Patti
Chief Financial Officer
MemorialCare Long beach medical Center/Miller children's & Women's Hospital
5629331905 | 7/10/2023 4:20 PM |
| Addresses | Shipping Address | Insert | Change Request | | Long Beach Memorial Medical Center, Inc., dba MemorialCare Miller Children's and Women's Hospital Lo
2801 Atlantic Av 1st FL B1A3020
Long Beach, CA 90806 | 4/21/2023 6:39 AM |
| Contacts | Authorizing Official | Update | Change Request | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331111 | Katz, Yair
Chief Executive MCWH SVP Peds
MemorialCare Miller Children's and Women's Hospital
5629338008 | 1/17/2023 7:02 AM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2021 3:42:12 PM | 8/26/2022 5:54:54 PM | 8/26/2022 5:54 PM |
| Contacts | Authorizing Official | Update | Change Request | Mmeje, Ikenna (Ike)
Chief Operating Officer
MemorialCare-Long Beach Medical Center, Miller Children's & Women's Hospital
5629331123 | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331111 | 8/5/2022 6:30 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2020 2:49:46 PM | 8/20/2021 3:42:12 PM | 8/20/2021 3:42 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Chang, Jennifer T
Director, Pharmacy Services
Long Beach Medical Center & Millier Children's and Women's Hospital
5629330282 | Chang, Jennifer T
Executive Director, Pharmacy Services
Long Beach Medical Center & Millier Children's and Women's Hospital
5629330282 | 3/2/2021 12:13 PM |
| Addresses | Shipping Address | Insert | Change Request | | Childrens VIllage Pharmacy
2701 Atlantic Av.
100
Long Beach, CA 90806 | 2/11/2021 9:12 AM |
| Contacts | Authorizing Official | Update | Change Request | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331111 | Mmeje, Ikenna (Ike)
Chief Operating Officer
MemorialCare-Long Beach Medical Center, Miller Children's & Women's Hospital
5629331123 | 9/28/2020 1:19 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 8/27/2020 2:49 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 8/27/2020 2:49 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 8/27/2020 2:49 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 8/27/2020 2:49 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2019 9:42:15 AM | 8/27/2020 2:49:46 PM | 8/27/2020 2:49 PM |
| Addresses | Main Address | Update | Change Request |
2801 Atlantic Avenue
Long Beach, CA 90806-1428 |
2801 Atlantic Avenue 1st FL B1A3020
Long Beach, CA 90806-1428 | 6/22/2020 12:17 PM |
| Addresses | Shipping Address | Delete | Change Request | Earl & Lorraine Miller Children's Hospital of Long Beach
2801 Atlantic Avenue
Long Beach, CA 90806 | | 3/11/2020 7:20 AM |
| Addresses | Shipping Address | Delete | Change Request | Infusion Care Pharmacy North
455 E. Columbia Street
Long Beach, CA 90806 | | 3/11/2020 7:20 AM |
| Addresses | Shipping Address | Insert | Change Request | | Long Beach Memorial Medical Center Outpatient Pharmacy
2801 Atlantic Avenue
Long Beach, CA 90806 | 3/11/2020 7:20 AM |
| Addresses | Shipping Address | Insert | Change Request | | Infusion Care Pharmacy North
455 E. Columbia Street
Suite 10
Long Beach, CA 90806 | 3/11/2020 7:20 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1003829722 ( ) | | 3/11/2020 7:20 AM |
| Details | Entity Name | Update | Change Request | Earl & Lorraine Miller Children's Hospital of Long Beach | Long Beach Memorial Medical Center, Inc., dba MemorialCare Miller Children's and Women's Hospital Long Beach | 3/11/2020 7:20 AM |
| Addresses | Shipping Address | Insert | Change Request | | Infusion Care Pharmacy North
455 E. Columbia Street
Long Beach, CA 90806 | 1/16/2020 9:43 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/8/2019 9:42 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | HSC30727F | 9/8/2019 9:42 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | CA | 9/8/2019 9:42 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/8/2019 9:42 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | HSP40727F | 9/8/2019 9:42 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | CA | 9/8/2019 9:42 AM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | HSP30727F (CA) | | 9/8/2019 9:42 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1053653782 | 9/8/2019 9:42 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1003829722 | 9/8/2019 9:42 AM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2018 10:27:00 AM | 9/8/2019 9:42:15 AM | 9/8/2019 9:42 AM |
| Contacts | Primary Contact | Update | Change Request | Hodding, Jane
Executive Director of Pharmacy
Memorialcare Long Beach Medical Center
5629330282 | Chang, Jennifer T
Director, Pharmacy Services
Long Beach Medical Center & Millier Children's and Women's Hospital
5629330282 | 6/4/2019 10:48 AM |
| Addresses | Billing Address | Insert | Change Request | | Earl & Lorraine Miller Children's Hospital of Long Beach
2801 Atlantic Avenue
Long Beach, CA 90806 | 1/20/2019 12:14 PM |
| Addresses | Shipping Address | Insert | Change Request | | Earl & Lorraine Miller Children's Hospital of Long Beach
2801 Atlantic Avenue
Long Beach, CA 90806 | 1/20/2019 12:14 PM |
| Addresses | Shipping Address | Delete | Change Request | Earl & Lorraine Miller Children's Hospital of Long Beach
2812 Long Beach Blvd
Long Beach, CA 90806 | | 1/20/2019 12:14 PM |
| Addresses | Shipping Address | Delete | Change Request | Infusion Care Pharmacy North
455 E. Columbia Street
Long Beach, CA 90806 | | 9/5/2018 7:52 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1053653782 ( ) | | 9/5/2018 7:52 AM |
| Details | Last Recertification Date | Update | Recertification | 11/16/2017 11:21:42 AM | 8/17/2018 10:27:00 AM | 8/17/2018 10:27 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2016 12:00:00 AM | 11/16/2017 11:21:42 AM | 11/16/2017 11:21 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331905 | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331111 | 10/20/2017 12:22 PM |
| Contacts | Signed By | Update | Profile Change Request | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331905 | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331111 | 10/20/2017 12:22 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Bishop, John
Chief Financial Officer
Long Beach Medical Center
5629331905 | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331905 | 10/20/2017 12:22 PM |
| Contacts | Signed By | Update | Profile Change Request | Bishop, John
Chief Financial Officer
Long Beach Medical Center
5629331905 | Bishop, John
Chief Executive Officer
Long Beach Medical Center
5629331905 | 10/20/2017 12:22 PM |
| Contacts | Authorizing Official | Update | | Bishop, John
Chief Financial Officer
5629331905 | Bishop, John
Chief Financial Officer
Long Beach Medical Center
5629331905 | 10/20/2017 12:16 PM |
| Contacts | Signed By | Update | | Bishop, John
Chief Financial Officer
5629331905 | Bishop, John
Chief Financial Officer
Long Beach Medical Center
5629331905 | 10/20/2017 12:16 PM |
| Contacts | Primary Contact | Update | | Hodding, Jane
Executive Director of Pharmacy
5629330282 | Hodding, Jane
Executive Director of Pharmacy
Memorialcare Long Beach Medical Center
5629330282 | 10/12/2017 3:49 PM |
| Contacts | Primary Contact | Insert | | | Hodding, Jane
Executive Director of Pharmacy
5629330282 | 2/16/2017 5:24 PM |
| Contacts | Authorizing Official | Insert | | | Bishop, John
Chief Financial Officer
5629331905 | 11/10/2016 8:22 PM |
| Contacts | Signed By | Insert | | | Bishop, John
Chief Financial Officer
5629331905 | 11/10/2016 8:22 PM |
| Addresses | Main Address | Insert | | |
2801 Atlantic Avenue
Long Beach, CA 90806-1428 | 10/13/2016 1:18 PM |
| Addresses | Shipping Address | Insert | | | Earl & Lorraine Miller Children's Hospital of Long Beach
2812 Long Beach Blvd
Long Beach, CA 90806 | 10/13/2016 1:18 PM |
| Addresses | Shipping Address | Insert | | | HomeCare Pharmacy
450 E. Spring Street
Suite 11
Long Beach, CA 90806 | 10/13/2016 1:18 PM |
| Addresses | Shipping Address | Insert | | | Infusion Care Pharmacy North
455 E. Columbia Street
Long Beach, CA 90806 | 10/13/2016 1:18 PM |
| Details | Last Recertification Date | Update | | 8/14/2015 12:00:00 AM | 8/16/2016 12:00:00 AM | 8/17/2016 3:22 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1972514503 | 4/15/2016 2:22 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1891890158 | 4/15/2016 2:22 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1053653782 | 4/15/2016 2:22 PM |
| Details | Last Recertification Date | Update | | 8/14/2014 12:00:00 AM | 8/14/2015 12:00:00 AM | 8/14/2015 11:28 AM |
| Details | Last Recertification Date | Update | | 8/28/2013 12:00:00 AM | 8/14/2014 12:00:00 AM | 8/14/2014 6:52 AM |
| Details | Comments Public | Insert | | | Entity name cannot be a pharmacy.
| 5/27/2014 5:19 PM |
| Details | Last Recertification Date | Update | | | 8/28/2013 12:00:00 AM | 8/28/2013 2:49 PM |
| Details | 340B ID | Update | | ISDR-PED053309-00 | PED053309-00 | 3/11/2013 3:09 PM |
| Dates | Participating Approval Date | Update | | | 3/11/2013 12:00:00 AM | 3/11/2013 3:09 PM |
| Details | State | Update | | Pending | Active | 3/11/2013 3:09 PM |
| Dates | Start Date | Update | | | 4/1/2013 12:00:00 AM | 3/11/2013 3:09 PM |
| Details | 340B ID | Update | | DR011413 | ISDR-PED053309-00 | 1/29/2013 1:13 PM |
| Details | 340B ID | Update | | ONLINE_REG | DR011413 | 1/15/2013 5:09 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/14/2013 7:50 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | HSP30727F | 1/14/2013 7:50 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 1/14/2013 7:50 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1477596583 | 1/14/2013 7:50 PM |
| Details | Last Recertification Date | Insert | | | | 1/14/2013 7:50 PM |
| Details | Grant Number | Insert | | | | 1/14/2013 7:50 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 1/14/2013 7:50 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/14/2013 7:50 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/14/2013 7:50 PM |
| Details | Medicare Provider Number | Insert | | | 053309 | 1/14/2013 7:50 PM |
| Details | Entity Name | Insert | | | Earl & Lorraine Miller Children's Hospital of Long Beach | 1/14/2013 7:50 PM |
| Details | Program Code | Insert | | | PED | 1/14/2013 7:50 PM |
| Details | Entity Subname | Insert | | | | 1/14/2013 7:50 PM |
| Dates | Participating Approval Date | Insert | | | | 1/14/2013 7:50 PM |
| Details | State | Insert | | | Pending | 1/14/2013 7:50 PM |
| Dates | Registration Date | Insert | | | 1/14/2013 12:00:00 AM | 1/14/2013 7:50 PM |
| Dates | Signed By Date | Insert | | | 1/14/2013 12:00:00 AM | 1/14/2013 7:50 PM |
| Dates | Start Date | Insert | | | | 1/14/2013 7:50 PM |
| Terminations | Termination Comments | Insert | | | | 1/14/2013 7:50 PM |
| Terminations | Termination Date | Insert | | | | 1/14/2013 7:50 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/14/2013 7:50 PM |
| Terminations | Termination Reason | Insert | | | | 1/14/2013 7:50 PM |