| Details | Last Recertification Date | Update | Recertification | 9/7/2023 2:20:48 PM | 9/9/2024 4:06:31 PM | 9/9/2024 4:06 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2022 2:27:52 PM | 9/7/2023 2:20:48 PM | 9/7/2023 2:20 PM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 050115 (CA) | | 9/7/2022 2:27 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457321317 | 9/7/2022 2:27 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | AZ | 9/7/2022 2:27 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457321317 | 9/7/2022 2:27 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CO | 9/7/2022 2:27 PM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2021 4:48:39 PM | 9/7/2022 2:27:52 PM | 9/7/2022 2:27 PM |
| Contacts | Authorizing Official | Update | Change Request | Bogert, Michael John
Chief Financial Officer
Palomar Health
7607406385 | Hansen, Diane Lynette
President & CEO
Palomar Health
7607406395 | 4/11/2022 2:26 PM |
| Addresses | Billing Address | Update | Recertification | Palomar Health
800 W. Valley Parkway, Suite #201
Escondido, CA 92025 | Palomar Health
120 Craven Road
200
San Marcos, CA 92078 | 9/2/2021 4:48 PM |
| Details | Last Recertification Date | Update | Recertification | 9/14/2020 1:28:15 PM | 9/2/2021 4:48:39 PM | 9/2/2021 4:48 PM |
| Contacts | Primary Contact | Update | Change Request | Skeets, Zephyr
Manager Pharmacy Business Operations
Palomar Health
4422811385 | Gelios, Dondreia
District Director Pharmacy Services
Palomar Health
4422811358 | 7/28/2021 8:19 AM |
| Addresses | Main Address | Update | Change Request |
15615 Pomerado Rd
Poway, CA 92064 |
2125 Citracado Pkwy
Ste 330
Escondido, CA 92029 | 4/14/2021 7:43 AM |
| Contacts | Authorizing Official | Update | Change Request | King, Hubert U.
Chief Financial Officer
Palomar Health
7607406385 | Bogert, Michael John
Chief Financial Officer
Palomar Health
7607406385 | 1/22/2021 11:02 AM |
| Addresses | Main Address | Update | Recertification |
555 E. Valley Parkway
Escondido, CA 92025 |
15615 Pomerado Rd
Poway, CA 92064 | 9/14/2020 1:28 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1457321317 ( ) | | 9/14/2020 1:28 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1457321317 | 9/14/2020 1:28 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/14/2020 1:28 PM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2019 5:56:06 PM | 9/14/2020 1:28:15 PM | 9/14/2020 1:28 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Bohorquez, Carlos A.
Chief FInancial Officer
Palomar Health
7607406385 | King, Hubert U.
Chief Financial Officer
Palomar Health
7607406385 | 8/31/2020 2:51 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2018 3:57:23 PM | 8/26/2019 5:56:06 PM | 8/26/2019 5:56 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Skeets, Zephyr
Manager Pharmacy Business Operations
Palomar Health
7607392849 | Skeets, Zephyr
Manager Pharmacy Business Operations
Palomar Health
4422811385 | 8/22/2019 1:00 PM |
| Contacts | Authorizing Official | Update | AO Change Request | King, Hubert U.
Chief Financial Officer
Palomar Health
7607406385 | Bohorquez, Carlos A.
Chief FInancial Officer
Palomar Health
7607406385 | 3/20/2019 8:54 AM |
| Contacts | Primary Contact | Update | Recertification | Lee, Jeremy
District Director Pharmacy Services
Palomar Health
7607393935 | Skeets, Zephyr
Manager Pharmacy Business Operations
Palomar Health
7607392849 | 8/23/2018 3:57 PM |
| Details | Last Recertification Date | Update | Recertification | 11/13/2017 5:29:14 PM | 8/23/2018 3:57:23 PM | 8/23/2018 3:57 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | King, Hubert U.
Interim Chief Financial Officer
Palomar Health
7607406385 | King, Hubert U.
Chief Financial Officer
Palomar Health
7607406385 | 8/15/2018 6:27 PM |
| Contacts | Authorizing Official | Update | Change Request | Hansen, Diane
Executive VP Finance
Palomar Health
7607406385 | King, Hubert U.
Interim Chief Financial Officer
Palomar Health
7607406385 | 1/11/2018 1:27 PM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2016 12:00:00 AM | 11/13/2017 5:29:14 PM | 11/13/2017 5:29 PM |
| Contacts | Authorizing Official | Update | | Hansen, Diane
Executive VP Finance
7607406385 | Hansen, Diane
Executive VP Finance
Palomar Health
7607406385 | 10/25/2017 12:00 PM |
| Contacts | Primary Contact | Update | | Lee, Jeremy
District Director Pharmacy Services
7607393935 | Lee, Jeremy
District Director Pharmacy Services
Palomar Health
7607393935 | 9/29/2017 12:55 PM |
| Contacts | Primary Contact | Insert | | | Lee, Jeremy
District Director Pharmacy Services
7607393935 | 8/1/2017 3:35 PM |
| Contacts | Signed By | Insert | | | Hemker, Robert A.
CEO
7607406393 | 8/1/2017 3:35 PM |
| Contacts | Authorizing Official | Insert | | | Hansen, Diane
Executive VP Finance
7607406385 | 8/1/2017 3:35 PM |
| Addresses | Main Address | Insert | | |
555 E. Valley Parkway
Escondido, CA 92025 | 7/26/2017 2:14 PM |
| Addresses | Billing Address | Insert | | | Palomar Health
800 W. Valley Parkway, Suite #201
Escondido, CA 92025 | 7/26/2017 2:14 PM |
| Details | Entity Subname | Update | | PHDC Outpatient Infusion Center | Chemotherapy (Infusion Center) | 7/26/2017 2:13 PM |
| Details | Entity Name | Update | | PALOMAR MEDICAL CENTER | PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido) | 6/15/2017 10:47 AM |
| Details | Last Recertification Date | Update | | 9/4/2015 12:00:00 AM | 9/2/2016 12:00:00 AM | 9/2/2016 1:40 PM |
| Details | Last Recertification Date | Update | | 8/29/2014 12:00:00 AM | 9/4/2015 12:00:00 AM | 9/4/2015 11:35 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 8/29/2014 7:31 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 050115 | 8/29/2014 7:31 AM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 8/29/2014 7:31 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1457321317 | 8/29/2014 7:31 AM |
| Details | Last Recertification Date | Update | | | 8/29/2014 12:00:00 AM | 8/29/2014 7:31 AM |
| Dates | Participating Approval Date | Update | | | 12/16/2013 12:00:00 AM | 12/16/2013 7:40 AM |
| Details | State | Update | | Pending | Active | 12/16/2013 7:40 AM |
| Dates | Start Date | Update | | | 1/1/2014 12:00:00 AM | 12/16/2013 7:40 AM |
| Details | 340B ID | Update | | Waiting on updated trial balance | DSH050115G | 12/14/2013 10:22 AM |
| Details | 340B ID | Update | | Waiting on return call | Waiting on updated trial balance | 12/13/2013 9:27 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | Waiting on return call | 12/11/2013 12:52 PM |
| Details | Last Recertification Date | Insert | | | | 12/9/2013 1:36 PM |
| Details | Grant Number | Insert | | | | 12/9/2013 1:36 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 12/9/2013 1:36 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 12/9/2013 1:36 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 12/9/2013 1:36 PM |
| Details | Medicare Provider Number | Insert | | | 050115 | 12/9/2013 1:36 PM |
| Details | Entity Name | Insert | | | PALOMAR MEDICAL CENTER | 12/9/2013 1:36 PM |
| Details | Program Code | Insert | | | DSH | 12/9/2013 1:36 PM |
| Details | Entity Subname | Insert | | | PHDC Outpatient Infusion Center | 12/9/2013 1:36 PM |
| Dates | Participating Approval Date | Insert | | | | 12/9/2013 1:36 PM |
| Details | State | Insert | | | Pending | 12/9/2013 1:36 PM |
| Dates | Registration Date | Insert | | | 12/9/2013 12:00:00 AM | 12/9/2013 1:36 PM |
| Dates | Signed By Date | Insert | | | 12/9/2013 12:00:00 AM | 12/9/2013 1:36 PM |
| Dates | Start Date | Insert | | | | 12/9/2013 1:36 PM |
| Terminations | Termination Comments | Insert | | | | 12/9/2013 1:36 PM |
| Terminations | Termination Date | Insert | | | | 12/9/2013 1:36 PM |
| Terminations | Termination Effective Date | Insert | | | | 12/9/2013 1:36 PM |
| Terminations | Termination Reason | Insert | | | | 12/9/2013 1:36 PM |