| Contacts | Authorizing Official | Update | Profile Change Request | Kiritani, Tracy
CFO
Community Medical Center
5593244844 | Kiritani, Tracy
VP Hospital Financial Operations
Community Medical Center
5593244844 | 2/19/2025 7:25 AM |
| Contacts | Signed By | Update | Profile Change Request | Kiritani, Tracy
CFO
Community Medical Center
5593244844 | Kiritani, Tracy
VP Hospital Financial Operations
Community Medical Center
5593244844 | 2/19/2025 7:25 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Magallon, Marcela
340B Manaer
Community Medical Center
5592441387 | Magallon, Marcela
340B Manager
Community Medical Center
5592441387 | 2/18/2025 7:06 PM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2023 2:10:17 PM | 8/15/2024 5:06:38 PM | 8/15/2024 5:06 PM |
| Addresses | Shipping Address | Insert | Change Request | | Vitalant, INC.
1524 West 14th Street
120
Tempe, AZ 85281 | 7/9/2024 7:31 AM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2022 10:57:54 AM | 8/25/2023 2:10:17 PM | 8/25/2023 2:10 PM |
| Contacts | Primary Contact | Update | Change Request | Weber, Joel
340B Program Director
Community Medical Center
5592311504 | Magallon, Marcela
340B Manaer
Community Medical Center
5592441387 | 11/7/2022 6:56 AM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2021 8:27:28 AM | 8/31/2022 10:57:54 AM | 8/31/2022 10:57 AM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2020 1:09:07 PM | 8/25/2021 8:27:28 AM | 8/25/2021 8:27 AM |
| Medicaid Billing | Medicaid: Number | Update | | HSP40492F | HSP40492F | 12/10/2020 4:18 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1316027709 ( ) | | 8/23/2020 1:09 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1316027709 | 8/23/2020 1:09 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 8/23/2020 1:09 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2019 7:35:13 AM | 8/23/2020 1:09:07 PM | 8/23/2020 1:09 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2018 2:06:59 PM | 9/3/2019 7:35:13 AM | 9/3/2019 7:35 AM |
| Details | Last Recertification Date | Update | Recertification | 11/20/2017 2:38:51 PM | 8/23/2018 2:06:59 PM | 8/23/2018 2:06 PM |
| Addresses | Shipping Address | Insert | Change Request | | Community Home Infusion
1630 E. Shaw Ave, suite 172
Fresno, CA 93710 | 12/22/2017 7:07 AM |
| Addresses | Billing Address | Insert | Recertification | | Community Regional Medical Center
P.O. Box 1232
Fresno, CA 93715-1231 | 11/20/2017 2:38 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2016 12:00:00 AM | 11/20/2017 2:38:51 PM | 11/20/2017 2:38 PM |
| Contacts | Authorizing Official | Update | | Kiritani, Tracy
CFO
5593244844 | Kiritani, Tracy
CFO
Community Medical Center
5593244844 | 9/21/2017 11:28 AM |
| Contacts | Signed By | Update | | Kiritani, Tracy
CFO
5593244844 | Kiritani, Tracy
CFO
Community Medical Center
5593244844 | 9/21/2017 11:28 AM |
| Contacts | Primary Contact | Update | | Weber, Joel
340B Program Director
5592311504 | Weber, Joel
340B Program Director
Community Medical Center
5592311504 | 9/18/2017 5:51 PM |
| Contacts | Primary Contact | Update | | Ahmed, Khaja
Director of Pharmacy
5593244053 | Weber, Joel
340B Program Director
5592311504 | 7/12/2017 1:31 PM |
| Contacts | Authorizing Official | Insert | | | Kiritani, Tracy
CFO
5593244844 | 7/12/2017 1:31 PM |
| Contacts | Signed By | Insert | | | Kiritani, Tracy
CFO
5593244844 | 7/12/2017 1:31 PM |
| Addresses | Main Address | Update | |
2755 Herndon Avenue
Clovis, CA 93612 |
2755 Herndon Avenue
Clovis, CA 93611 | 5/23/2017 6:01 PM |
| Addresses | Main Address | Insert | | |
2755 Herndon Avenue
Clovis, CA 93612 | 5/23/2017 6:01 PM |
| Addresses | Shipping Address | Insert | | | Fresno Community Hospital & Medical Center dba Clovis Community Medical Center
2755 Herndon Avenue
Clovis, CA 93611-6800 | 5/23/2017 6:01 PM |
| Contacts | Primary Contact | Insert | | | Ahmed, Khaja
Director of Pharmacy
5593244053 | 8/30/2016 12:03 PM |
| Details | Last Recertification Date | Update | | 8/31/2015 12:00:00 AM | 8/30/2016 12:00:00 AM | 8/30/2016 12:03 PM |
| Details | Last Recertification Date | Update | | 8/13/2014 12:00:00 AM | 8/31/2015 12:00:00 AM | 8/31/2015 12:07 PM |
| Details | Last Recertification Date | Update | | | 8/13/2014 12:00:00 AM | 8/13/2014 2:10 PM |
| Dates | Participating Approval Date | Update | | | 11/26/2013 12:00:00 AM | 11/26/2013 9:56 AM |
| Details | State | Update | | Pending | Active | 11/26/2013 9:56 AM |
| Dates | Start Date | Update | | | 1/1/2014 12:00:00 AM | 11/26/2013 9:56 AM |
| Details | 340B ID | Update | | ONLINE_REG | DSH050492 | 11/22/2013 9:15 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/3/2013 12:11 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | HSP40492F | 10/3/2013 12:11 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 10/3/2013 12:11 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1316027709 | 10/3/2013 12:11 PM |
| Details | Last Recertification Date | Insert | | | | 10/3/2013 12:11 PM |
| Details | Grant Number | Insert | | | | 10/3/2013 12:11 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 10/3/2013 12:11 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/3/2013 12:11 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/3/2013 12:11 PM |
| Details | Medicare Provider Number | Insert | | | 050492 | 10/3/2013 12:11 PM |
| Details | Entity Name | Insert | | | Fresno Community Hospital & Medical Center dba Clovis Community Medical Center | 10/3/2013 12:11 PM |
| Details | Program Code | Insert | | | DSH | 10/3/2013 12:11 PM |
| Details | Entity Subname | Insert | | | | 10/3/2013 12:11 PM |
| Dates | Participating Approval Date | Insert | | | | 10/3/2013 12:11 PM |
| Details | State | Insert | | | Pending | 10/3/2013 12:11 PM |
| Dates | Registration Date | Insert | | | 10/3/2013 12:00:00 AM | 10/3/2013 12:11 PM |
| Dates | Signed By Date | Insert | | | 10/3/2013 12:00:00 AM | 10/3/2013 12:11 PM |
| Dates | Start Date | Insert | | | | 10/3/2013 12:11 PM |
| Terminations | Termination Comments | Insert | | | | 10/3/2013 12:11 PM |
| Terminations | Termination Date | Insert | | | | 10/3/2013 12:11 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/3/2013 12:11 PM |
| Terminations | Termination Reason | Insert | | | | 10/3/2013 12:11 PM |