Covered Entity Details

SCH030055-02 Kingman Regional Medical Center (Active) - information as of 5/10/2025 11:05:25 PM

Main Details

Name

Kingman Regional Medical Center

Subdivision Name

Radiology Clinic-Sycamore Ave

Type

Sole Community Hospital

Rural

340B ID

SCH030055-02

Medicare Provider Number

030055

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2013

Participating Start Date

7/1/2013

Participating Approval Date

6/13/2013

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

kingman regional medical center
Joshua Hoffman, Chief Financial Officer
(928) 263-3087

Primary Contact

Kingman Regional Medical Center
Michael Todd Moore, Informatics Pharmacist
(928) 263-4884

Addresses

Street Address

1033 Sycamore Ave
Kingman, AZ 86409

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
AZ	AZ-20256,AZ-489947	1265423917,1992286298

Shipping Addresses

Same as Street Address

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
SCH030055-01	Child	SCH	Kingman Regional Medical Center	Pain Management Clinic	3801 Santa Rosa	Kingman	AZ	Active
SCH030055-02	Child	SCH	Kingman Regional Medical Center	Radiology Clinic-Sycamore Ave	1033 Sycamore Ave	Kingman	AZ	Active
SCH030055-03	Child	SCH	Kingman Regional Medical Center	Oncology Clinic	1739 Beverly Avenue	Kingman	AZ	Active
SCH030055-04	Child	SCH	Kingman Regional Medical Center	Outpatient Infusion Center	1739 Beverly Avenue	Kingman	AZ	Active
SCH030055-05	Child	SCH	Kingman Regional Medical Center	Radiation Oncology Clinic	1739 Beverly Avenue	Kingman	AZ	Active
SCH030055-06	Child	SCH	Kingman Regional Medical Center	Disease Management Clinic	3801 Santa Rosa Drive	Kingman	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	1033 Sycamore Street Kingman, AZ 86409	1033 Sycamore Ave Kingman, AZ 86409	1/14/2025 11:05 AM
Details	Entity Subname	Update	Change Request	Radiology Clinic-Sycamore Street	Radiology Clinic-Sycamore Ave	1/14/2025 11:05 AM
Details	Last Recertification Date	Update	Recertification	9/1/2023 1:43:54 PM	9/4/2024 6:51:20 PM	9/4/2024 6:51 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265423917 (CA)		7/15/2024 7:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265423917 (ID)		7/15/2024 7:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1265423917 (NV)		7/15/2024 7:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265423917 (CA)		7/15/2024 7:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1992286298 (CA)		7/15/2024 7:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265423917 (ID)		7/15/2024 7:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1992286298 (ID)		7/15/2024 7:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265423917 (NV)		7/15/2024 7:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1992286298 (NV)		7/15/2024 7:28 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	9000164905 (CO)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	942916102002 (IL)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	300021800 (IN)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1265423917 (MT)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	A7699 (NM)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100706210A (OK)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	51854 (OR)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	108621702 (TX)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1265423917 (UT)		9/1/2023 1:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1265423917 (WY)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (CO)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (CO)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (IL)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (IL)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (IN)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (IN)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (MT)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (MT)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (NM)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (OK)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (OK)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (OR)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (OR)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (TX)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (TX)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (UT)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (UT)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (WY)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (WY)		9/1/2023 1:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (NM)		9/1/2023 1:43 PM
Details	Last Recertification Date	Update	Recertification	9/15/2022 11:11:15 AM	9/1/2023 1:43:54 PM	9/1/2023 1:43 PM
Contacts	Authorizing Official	Update	Change Request	Dimambro, Christina CFO kingman regional medical center 9282634003	Hoffman, Joshua Chief Financial Officer kingman regional medical center 9282633087	2/16/2023 7:46 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1749338 (LA)		9/15/2022 11:11 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1265423917 (MI)		9/15/2022 11:11 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	10657990001 (PA)		9/15/2022 11:11 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1265423917 (WI)		9/15/2022 11:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (LA)		9/15/2022 11:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (LA)		9/15/2022 11:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (MI)		9/15/2022 11:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (MI)		9/15/2022 11:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (PA)		9/15/2022 11:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (PA)		9/15/2022 11:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1265423917 (WI)		9/15/2022 11:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1992286298 (WI)		9/15/2022 11:11 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 12:22:44 PM	9/15/2022 11:11:15 AM	9/15/2022 11:11 AM
Contacts	Authorizing Official	Update	Change Request	Blanchard, Tim CFO Kingman Regional Medical Center 9286818668	Dimambro, Christina CFO kingman regional medical center 9282634003	1/10/2022 7:50 AM
Contacts	Primary Contact	Update	Recertification	Latimer, William Bruce Director Pharmacy Services Kingman Regional Medical Center 9287570617	Moore, Michael Todd Informatics Pharmacist Kingman Regional Medical Center 9282634884	9/9/2021 12:22 PM
Details	Last Recertification Date	Update	Recertification	9/4/2020 1:35:50 PM	9/9/2021 12:22:44 PM	9/9/2021 12:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		9000164905	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		942916102002	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300021800	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1749338	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MT	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		A7699	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NV	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100706210A	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		51854	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10657990001	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		108621702	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		UT	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WY	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		AZ-489947	9/4/2020 1:35 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265423917	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/4/2020 1:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992286298	9/4/2020 1:35 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/4/2020 1:35 PM
Details	Last Recertification Date	Update	Recertification	9/10/2019 6:24:21 PM	9/4/2020 1:35:50 PM	9/4/2020 1:35 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 3:25:27 PM	9/10/2019 6:24:21 PM	9/10/2019 6:24 PM
Details	Last Recertification Date	Update	Recertification	11/16/2017 12:14:05 PM	8/30/2018 3:25:27 PM	8/30/2018 3:25 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/16/2017 12:14:05 PM	11/16/2017 12:14 PM
Contacts	Authorizing Official	Update		Blanchard, Tim CFO 9286818668	Blanchard, Tim CFO Kingman Regional Medical Center 9286818668	10/17/2017 2:34 PM
Contacts	Signed By	Update		Blanchard, Tim CFO 9286818668	Blanchard, Tim CFO Kingman Regional Medical Center 9286818668	10/17/2017 2:34 PM
Contacts	Primary Contact	Update	Profile Change Request	Latimer, Bruce Director Pharmacy Services Kingman Regional Medical Center 9237570617	Latimer, William Bruce Director Pharmacy Services Kingman Regional Medical Center 9287570617	10/11/2017 9:34 PM
Contacts	Primary Contact	Update		Latimer, Bruce Director Pharmacy Services 9237570617	Latimer, Bruce Director Pharmacy Services Kingman Regional Medical Center 9237570617	10/11/2017 9:16 PM
Contacts	Primary Contact	Insert			Latimer, Bruce Director Pharmacy Services 9237570617	7/26/2017 12:27 PM
Contacts	Authorizing Official	Insert			Blanchard, Tim CFO 9286818668	7/26/2017 12:27 PM
Contacts	Signed By	Insert			Blanchard, Tim CFO 9286818668	7/26/2017 12:27 PM
Addresses	Main Address	Insert			1033 Sycamore Street Kingman, AZ 86409	2/16/2017 2:42 PM
Details	Last Recertification Date	Update		8/19/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/1/2016 9:53 PM
Details	Last Recertification Date	Update		8/14/2014 12:00:00 AM	8/19/2015 12:00:00 AM	8/19/2015 2:54 PM
Details	Last Recertification Date	Update		8/23/2013 12:00:00 AM	8/14/2014 12:00:00 AM	8/14/2014 6:46 AM
Details	Last Recertification Date	Update		8/23/2013 7:07:52 PM	8/23/2013 12:00:00 AM	4/2/2014 3:40 PM
Details	Last Recertification Date	Update			8/23/2013 7:07:52 PM	8/23/2013 7:07 PM
Details	340B ID	Update		ISJMSCH030055-02	SCH030055-02	6/13/2013 3:13 PM
Dates	Participating Approval Date	Update			6/13/2013 12:00:00 AM	6/13/2013 3:13 PM
Details	State	Update		Pending	Active	6/13/2013 3:13 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	6/13/2013 3:13 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISJMSCH030055-02	5/14/2013 11:31 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/12/2013 2:51 PM
Medicaid Billing	Medicaid: Number	Insert			AZ-20256	4/12/2013 2:51 PM
Medicaid Billing	Medicaid: State	Insert			AZ	4/12/2013 2:51 PM
Details	Last Recertification Date	Insert				4/12/2013 2:51 PM
Details	Grant Number	Insert				4/12/2013 2:51 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/12/2013 2:51 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2013 2:51 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2013 2:51 PM
Details	Medicare Provider Number	Insert			030055	4/12/2013 2:51 PM
Details	Entity Name	Insert			Kingman Regional Medical Center	4/12/2013 2:51 PM
Details	Program Code	Insert			SCH	4/12/2013 2:51 PM
Details	Entity Subname	Insert			Radiology Clinic-Sycamore Street	4/12/2013 2:51 PM
Dates	Participating Approval Date	Insert				4/12/2013 2:51 PM
Details	State	Insert			Pending	4/12/2013 2:51 PM
Dates	Registration Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 2:51 PM
Dates	Signed By Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 2:51 PM
Dates	Start Date	Insert				4/12/2013 2:51 PM
Terminations	Termination Comments	Insert				4/12/2013 2:51 PM
Terminations	Termination Date	Insert				4/12/2013 2:51 PM
Terminations	Termination Effective Date	Insert				4/12/2013 2:51 PM
Terminations	Termination Reason	Insert				4/12/2013 2:51 PM