| Details | Last Recertification Date | Update | Recertification | 8/28/2023 12:22:10 PM | 8/28/2024 2:50:32 PM | 8/28/2024 2:50 PM |
| Contacts | Authorizing Official | Update | Change Request | Holmes, Nicholas Matthew
Senior VP, Chief Operating Officer
Rady Children's Hospital San Diego
8589665948 | Davis, Charles Brendan
Interim Chief Operating Officer
Rady Children's Hospital San Diego
8589664001 | 2/12/2024 8:32 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2022 12:24:38 PM | 8/28/2023 12:22:10 PM | 8/28/2023 12:22 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2021 7:17:28 PM | 8/29/2022 12:24:38 PM | 8/29/2022 12:24 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2020 10:29:04 AM | 8/16/2021 7:17:28 PM | 8/16/2021 7:17 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1710065933 ( ) | | 9/7/2020 10:29 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1710065933 | 9/7/2020 10:29 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/7/2020 10:29 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1851303994 | 9/7/2020 10:29 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/7/2020 10:29 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1669617197 | 9/7/2020 10:29 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/7/2020 10:29 AM |
| Contacts | Primary Contact | Update | Recertification | Sey, Mark
Pharmicist in Chief
Rady Childrens Hospital
8589668023 | Abe, Chris
VP, Operations
Rady Children's Hospital San Diego
8589665968 | 9/7/2020 10:29 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2019 1:59:52 PM | 9/7/2020 10:29:04 AM | 9/7/2020 10:29 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/26/2019 1:59:52 PM | 8/26/2019 1:59 PM |
| Contacts | Primary Contact | Update | Change Request | Scott, Jamie Leigh
340B Program Manager
Rady Children's Hospital
8589661700-5024 | Sey, Mark
Pharmicist in Chief
Rady Childrens Hospital
8589668023 | 4/22/2019 1:24 PM |
| Addresses | Main Address | Update | Change Request |
3030 Children's Way
Medical Office Building, 4th Floor
San Diego, CA 92123 |
3030 Children's Way
Medical Office Building,1st Floor
San Diego, CA 92123 | 4/8/2019 8:26 AM |
| Details | State | Update | | Approved | Active | 4/1/2019 12:05 AM |
| Addresses | Billing Address | Insert | Reinstatement | | Rady Children's Hospital
3020 Children's Way
San Diego, CA 92123 | 2/7/2019 1:35 PM |
| Addresses | Shipping Address | Insert | Reinstatement | | Rady Children's Hospital
3020 Children's Way
San Diego, CA 92123 | 2/7/2019 1:35 PM |
| Contacts | Primary Contact | Update | Reinstatement | Abe, Chris
Senior Director Ancillary and Support Services
Rady Children's Hospital San Diego
8589665968 | Scott, Jamie Leigh
340B Program Manager
Rady Children's Hospital
8589661700-5024 | 2/7/2019 1:35 PM |
| Contacts | Signed By | Update | Reinstatement | Norton, Margareta E.
Chief Operating Officer
Rady Children's Hospital-San Diego
8589664006 | Holmes, Nicholas Matthew
Senior VP, Chief Operating Officer
Rady Children's Hospital San Diego
8589665948 | 2/7/2019 1:35 PM |
| Dates | Participating Approval Date | Update | Reinstatement | | 2/7/2019 1:35:41 PM | 2/7/2019 1:35 PM |
| Details | State | Update | Reinstatement | Pending | Approved | 2/7/2019 1:35 PM |
| Dates | Signed By Date | Update | Reinstatement | 10/15/2014 12:00:00 AM | 2/4/2019 1:56:11 PM | 2/7/2019 1:35 PM |
| Dates | Start Date | Update | Reinstatement | | 4/1/2019 12:00:00 AM | 2/7/2019 1:35 PM |
| Details | Comments Public | Insert | Reinstatement | | Participated starting 1/1/2015, terminated 1/1/2015. Reinstated 4/1/2019. | 2/7/2019 9:56 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 12/15/2014 12:00:00 AM | | 1/4/2019 2:07 PM |
| Dates | Participating Approval Date | Update | Reinstatement | 12/10/2014 12:00:00 AM | | 1/4/2019 2:07 PM |
| Details | State | Update | Reinstatement | Terminated | Pending | 1/4/2019 2:07 PM |
| Dates | Registration Date | Update | Reinstatement | 10/15/2014 12:00:00 AM | 1/4/2019 2:07:57 PM | 1/4/2019 2:07 PM |
| Dates | Start Date | Update | Reinstatement | 1/1/2015 12:00:00 AM | | 1/4/2019 2:07 PM |
| Terminations | Termination Comments | Update | Reinstatement | Clinic is located within the four walls of the hospital. No 340B drugs have been purchased to date | | 1/4/2019 2:07 PM |
| Terminations | Termination Date | Update | Reinstatement | 1/1/2015 12:00:00 AM | | 1/4/2019 2:07 PM |
| Terminations | Termination Effective Date | Update | Reinstatement | 12/15/2014 12:00:00 AM | | 1/4/2019 2:07 PM |
| Terminations | Termination Reason | Update | Reinstatement | Site closure | | 1/4/2019 2:07 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Norton, Margareta E.
Chief Operating Officer
Rady Children's Hospital-San Diego
8589664006 | Holmes, Nicholas Matthew
Senior VP, Chief Operating Officer
Rady Children's Hospital San Diego
8589665948 | 4/12/2018 7:23 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Norton, Margareta E.
Chief Operating Officer
Rady Children's Hospital-San Diego
8589666004 | Norton, Margareta E.
Chief Operating Officer
Rady Children's Hospital-San Diego
8589664006 | 10/25/2017 2:20 PM |
| Contacts | Signed By | Update | Profile Change Request | Norton, Margareta E.
Chief Operating Officer
Rady Children's Hospital-San Diego
8589666004 | Norton, Margareta E.
Chief Operating Officer
Rady Children's Hospital-San Diego
8589664006 | 10/25/2017 2:20 PM |
| Contacts | Primary Contact | Update | Recertification | Abe, Chris
Senior Director Ancillary and Support Services
8589665968 | Abe, Chris
Senior Director Ancillary and Support Services
Rady Children's Hospital San Diego
8589665968 | 10/25/2017 2:19 PM |
| Contacts | Authorizing Official | Update | | Norton, Margareta E.
Chief Operating Officer
8589666004 | Norton, Margareta E.
Chief Operating Officer
Rady Children's Hospital-San Diego
8589666004 | 10/25/2017 2:09 PM |
| Contacts | Signed By | Update | | Norton, Margareta E.
Chief Operating Officer
8589666004 | Norton, Margareta E.
Chief Operating Officer
Rady Children's Hospital-San Diego
8589666004 | 10/25/2017 2:09 PM |
| Contacts | Authorizing Official | Insert | | | Norton, Margareta E.
Chief Operating Officer
8589666004 | 8/30/2017 12:44 PM |
| Contacts | Signed By | Insert | | | Norton, Margareta E.
Chief Operating Officer
8589666004 | 8/30/2017 12:44 PM |
| Contacts | Primary Contact | Insert | | | Abe, Chris
Senior Director Ancillary and Support Services
8589665968 | 8/30/2017 12:44 PM |
| Addresses | Main Address | Insert | | |
3030 Children's Way
Medical Office Building, 4th Floor
San Diego, CA 92123 | 12/30/2014 4:54 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 12/15/2014 12:00:00 AM | 12/30/2014 4:54 PM |
| Details | State | Update | | Active | Terminated | 12/30/2014 4:54 PM |
| Terminations | Termination Comments | Update | | | Clinic is located within the four walls of the hospital. No 340B drugs have been purchased to date | 12/30/2014 4:54 PM |
| Terminations | Termination Date | Update | | | 1/1/2015 12:00:00 AM | 12/30/2014 4:54 PM |
| Terminations | Termination Effective Date | Update | | | 12/15/2014 12:00:00 AM | 12/30/2014 4:54 PM |
| Terminations | Termination Reason | Update | | | Site closure | 12/30/2014 4:54 PM |
| Dates | Participating Approval Date | Update | | | 12/10/2014 12:00:00 AM | 12/10/2014 3:05 PM |
| Details | State | Update | | Pending | Active | 12/10/2014 3:05 PM |
| Dates | Start Date | Update | | | 1/1/2015 12:00:00 AM | 12/10/2014 3:05 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_47513 | PED053303-07 | 11/25/2014 4:09 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_47513 | 10/15/2014 1:14 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/15/2014 1:14 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 1710065933 | 10/15/2014 1:14 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 10/15/2014 1:14 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1710065933 | 10/15/2014 1:14 PM |
| Details | Last Recertification Date | Insert | | | | 10/15/2014 1:14 PM |
| Details | Grant Number | Insert | | | | 10/15/2014 1:14 PM |
| Details | 340B ID | Insert | | | | 10/15/2014 1:14 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/15/2014 1:14 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/15/2014 1:14 PM |
| Details | Medicare Provider Number | Insert | | | 053303 | 10/15/2014 1:14 PM |
| Details | Entity Name | Insert | | | RADY CHILDRENS HOSPITAL - SAN DIEGO | 10/15/2014 1:14 PM |
| Details | Program Code | Insert | | | PED | 10/15/2014 1:14 PM |
| Details | Entity Subname | Insert | | | Otolaryngology | 10/15/2014 1:14 PM |
| Dates | Participating Approval Date | Insert | | | | 10/15/2014 1:14 PM |
| Details | State | Insert | | | Pending | 10/15/2014 1:14 PM |
| Dates | Registration Date | Insert | | | 10/15/2014 12:00:00 AM | 10/15/2014 1:14 PM |
| Dates | Signed By Date | Insert | | | 10/15/2014 12:00:00 AM | 10/15/2014 1:14 PM |
| Dates | Start Date | Insert | | | | 10/15/2014 1:14 PM |
| Terminations | Termination Comments | Insert | | | | 10/15/2014 1:14 PM |
| Terminations | Termination Date | Insert | | | | 10/15/2014 1:14 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/15/2014 1:14 PM |
| Terminations | Termination Reason | Insert | | | | 10/15/2014 1:14 PM |