Covered Entity Details

DSH050441 STANFORD HEALTH CARE (Active) - information as of 6/7/2025 4:47:11 AM

Main Details

Name

STANFORD HEALTH CARE

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050441

Medicare Provider Number

050441

Additional Details

Current Program Status

Active

Registration Date

4/8/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/13/2015

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Stanford Health Care
Linda Hoff, CFO
(650) 497-0391

Primary Contact

Stanford Health Care
Muang Lopez, 340B Business Analyst
(707) 688-1874

Addresses

Street Address

300 PASTEUR DRIVE
Stanford, CA 94305

Billing Address

Stanford Health Care
300 Pasteur Drive
Stanford, CA 94305

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
NV	1288115	1871543215
CA	HSC00441H	1053835595,1871543215
AZ	635477	1871543215
CO	9000177684	1871543215
ME	131360026	1871543215
OK	200105830C	1871543215
OR	500400133	1871543215
UT	1026297	1871543215
MT		1871543215

Shipping Addresses

Shipping Address 1

Stanford Health Care - (Central Pharmacy)
300 Pasteur Drive
RM H0301
Stanford, CA 94305

Shipping Address 2

Stanford South Bay Cancer Center Pharmacy
2589 Samaritan Drive
RM# 4205
San Jose, CA 95124

Shipping Address 3

Stanford Health Care - (Outpatient Center Pharmacy)
450 Broadway Street
Pavilion A 3rd Floor
L030225
Redwood City, CA 94063

Shipping Address 4

Stanford Health Care Pavillion C-1 Pharmacy
450 Broadway
RM L011102
Redwood City, CA 94063

Shipping Address 5

Stanford Health Care Pharmacy - (ITA Cancer Center)
875 Blake Wilbur DR
RM CC 2308
Palo Alto, CA 94304

Shipping Address 6

Stanford Health Care, 500P Hospital
500 Pasteur Dr.
Stanford, CA 94305-1048

Shipping Address 7

Stanford Health Care - (Redwood Outpatient Clinic Pharmacy)
450 Broadway St.
Pavillion B, 3rd FL
L030823
Redwood City, CA 94063

Shipping Address 8

Stanford Emeryville Health Center Pharmacy
5800 Hollis Street
Room 2325
Emeryville, CA 94608

Shipping Address 9

Stanford Health Care Pharmacy
875 Blake Wilbur Dr
STE CC1102
Palo Alto, CA 94305

Shipping Address 10

Stanford Neuroscience Health Center Pharmacy
213 Quarry Road
Room 2726
Palo Alto, CA 94304

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACARIAHEALTH PHARMACY #14, INC.	4151 E COMMERCE WAY # 1041		SACRAMENTO	CA	95834-9679	01/13/2018	04/01/2018	12/31/2024	12/31/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/16/2018	07/01/2018		04/16/2018
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/16/2018	07/01/2018		04/16/2018
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/16/2018	07/01/2018		04/16/2018
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/16/2018	07/01/2018	10/07/2019	10/15/2019
Contract Detail	ACCREDO HEALTH GROUP INC	2410 WARDLOW RD	STE 101	CORONA	CA	92878	04/15/2020	04/20/2020		04/20/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/16/2018	07/01/2018	07/01/2024	10/03/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/14/2023	07/01/2023		07/01/2023
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/01/2019	07/01/2019		07/01/2019
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	12/06/2017	01/01/2018	07/28/2020	07/28/2020
Contract Detail	AVELLA OF SACRAMENTO, INC.	2288 AUBURN BLVD #102		SACRAMENTO	CA	95821	12/06/2017	01/01/2018	07/28/2020	07/28/2020
Contract Detail	BIOLOGICS	BIOLOGICS BY MCKESSON	13000 WESTON PKWY, STE 105	CARY	NC	27513-2250	10/15/2018	01/01/2019	07/16/2020	08/14/2020
Contract Detail	BIOLOGICS, INC.	BIOLOGICS BY MCKESSON	11800 WESTON PARKWAY	CARY	NC	27513	07/08/2020	07/08/2020		07/13/2020
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	01/12/2024	04/01/2024		04/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	01/12/2024	04/01/2024		04/01/2024
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/13/2018	04/01/2018		01/13/2018
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/13/2018	04/01/2018		01/13/2018
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/03/2022	04/01/2022		04/01/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/13/2018	04/01/2018		01/13/2018
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/03/2022	04/01/2022		04/01/2022
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/16/2018	07/01/2018		04/16/2018
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/08/2020	01/01/2021	01/24/2022	02/16/2022
Contract Detail	LPCH CHILDREN'S HOME PHARMACY	4200 BOHANNON DR STE 110		MENLO PARK	CA	94025	07/19/2017	10/01/2017		10/01/2017
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/13/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	10/13/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM INFUSION SERVICES 401, LLC	4610 NORTHGATE BLVD.	STE. 130	SACRAMENTO	CA	95834-1154	10/08/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	07/06/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/14/2022	01/24/2022		01/24/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/08/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/13/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	10/08/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/08/2020	07/08/2020		07/22/2020
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	07/08/2020	07/08/2020	06/18/2021	10/13/2021
Contract Detail	PRECISE SPECIALTY CARE PHARMACY	26 CHESTNUT AVENUE		SOUTH SAN FRANCISCO	CA	94080-3229	01/15/2020	04/01/2020	10/07/2020	10/08/2020
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/16/2018	07/01/2018	10/01/2022	10/21/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/13/2018	04/01/2018		01/13/2018
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/11/2025	07/01/2025		04/11/2025
Contract Detail	SINA DRUG, LLC D/B/A ONCO360	15990 N GREENWAY HAYDEN LOOP STE D-100		SCOTTSDALE	AZ	85260	04/11/2025	07/01/2025		04/11/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/16/2018	07/01/2018		04/16/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/16/2018	07/01/2018	10/10/2021	10/13/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/16/2018	07/01/2018		04/16/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/16/2018	07/01/2018		04/16/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050441A	Child	DSH	STANFORD HEALTH CARE	MSPECIALTY PORTOLA VALLEY-TECH	3220 Alpine Road	Portola Valley	CA	Terminated
DSH050441AA	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-BL Wilbur Multi-specialty-Tech	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441AB	Child	DSH	STANFORD HOSPITAL & CLINICS	Electroencephalography	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441AC	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441AD	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic-OP CTR Dermatology	2433 Central Ave	Alameda	CA	Terminated
DSH050441AE	Child	DSH	STANFORD HEALTH CARE	Byers Surgery Clinic	2452 Watson Ct	Palo Alto	CA	Active
DSH050441AF	Child	DSH	STANFORD HEALTH CARE	Ophthalmology Clinic-Ophthalmology	2452 Watson Ct	Palo Alto	CA	Terminated
DSH050441AG	Child	DSH	STANFORD HEALTH CARE	Ophthalmology Clinic-Laser Excimer	2452 Watson Ct	Palo Alto	CA	Active
DSH050441AH	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic-Dermatology-Hayward	27212 Caloroga Ave	Hayward	CA	Terminated
DSH050441AJ	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Gastroenterology-Portola Valley	3240 Alpine Rd	Portola Valley	CA	Terminated
DSH050441AK	Child	DSH	STANFORD HEALTH CARE	Clinic-Orthopaedics-Portola Valley	3260 Alpine Rd	Portola Valley	CA	Terminated
DSH050441AL	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic	341 Galvez St	Stanford	CA	Terminated
DSH050441AM	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic-Orthopaedics-Plastic Surgery/Hand	450 Broadway St	Redwood City	CA	Active
DSH050441AN	Child	DSH	STANFORD HOSPITAL & CLINICS	Medical Specialties/Immunology-RWC	440 Broadway St	Redwood City	CA	Terminated
DSH050441AP	Child	DSH	STANFORD HOSPITAL & CLINICS	Physical Therapy-Rehab-Ortho Sports Therapy	440 Broadway St	Redwood City	CA	Terminated
DSH050441AQ	Child	DSH	STANFORD HEALTH CARE	Ortho Clinic-Orthopaedics	450 Broadway St	Redwood City	CA	Active
DSH050441AR	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Immunology-Ortho OPC	450 Broadway St	Redwood City	CA	Terminated
DSH050441AS	Child	DSH	STANFORD HOSPITAL & CLINICS	Surgery Clinic-Vascular Lab-RWC	450 Broadway St	Redwood City	CA	Terminated
DSH050441AT	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic-Otolaryngology-OPC	450 Broadway St	Redwood City	CA	Terminated
DSH050441AU	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic- OP CTR Outpatient Surgery Center	450 Broadway St	Redwood City	CA	Active
DSH050441AV	Child	DSH	STANFORD HOSPITAL & CLINICS	Physical Therapy-Rehab-Hand Therapy	450 Broadway St	Redwood City	CA	Terminated
DSH050441AW	Child	DSH	STANFORD HOSPITAL & CLINICS	MRI-Radiology-MRI OPC	450 Broadway St	Redwood City	CA	Terminated
DSH050441AX	Child	DSH	STANFORD HOSPITAL & CLINICS	CT Scan-Radiology-CT Scan OPC	440 Broadway St	Redwood City	CA	Terminated
DSH050441AY	Child	DSH	STANFORD HOSPITAL & CLINICS	Radioisotope-Radiology-Nuclear Med OPC	440 Broadway St	Redwood City	CA	Terminated
DSH050441AZ	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic-OP CTR ULTRASOUND	440 Broadway St	Redwood City	CA	Terminated
DSH050441B	Child	DSH	STANFORD HEALTH CARE	PRIMARY CARE - PORTOLA VALLEY	3250 Alpine Road	Portola Valley	CA	Active
DSH050441BA	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic-OPC	440 Broadway St	Redwood City	CA	Terminated
DSH050441BB	Child	DSH	STANFORD HEALTH CARE	MRI-Radiology-MRI Sherman	451 Sherman Ave	Palo Alto	CA	Terminated
DSH050441BC	Child	DSH	STANFORD HEALTH CARE	CT Scan-Radiology-CT Scan-Sherman	451 Sherman Ave	Palo Alto	CA	Terminated
DSH050441BD	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic-Dermatology Medicine-Vaden	866 Campus Dr	Stanford	CA	Terminated
DSH050441BE	Child	DSH	STANFORD HOSPITAL & CLINICS	Ophthalmology Clinic-Vaden	866 Campus Dr	Stanford	CA	Terminated
DSH050441BF	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Lymphoma Clinic	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BG	Child	DSH	STANFORD HEALTH CARE	Breast Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BH	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Cutaneous Oncology	875 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441BJ	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Neuro Oncology	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BK	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Hematology	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BL	Child	DSH	STANFORD HEALTH CARE	GYN Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BM	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Apheresis	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BN	Child	DSH	STANFORD HEALTH CARE	BMT Clinic-Infusion Treatment Area	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BP	Child	DSH	STANFORD HEALTH CARE	Clinic-Infusion Center-Redwood City	440 Broadway St	Redwood City	CA	Active
DSH050441BQ	Child	DSH	STANFORD HEALTH CARE	Radiology-Therapeutic-Radiation Therapy CC	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BR	Child	DSH	STANFORD HEALTH CARE	Radiology-Therapeutic-Radiation Oncology	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BS	Child	DSH	STANFORD HEALTH CARE	Radiology-Diagnostic-Mammography CC	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BT	Child	DSH	STANFORD HEALTH CARE	Gastro Intestinal-Gastroenterology	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441BU	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Apheresis	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441BV	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Sarcoma	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441BW	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Lymphoma	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441BX	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Breast Oncology	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441BY	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-GI Oncology-BW	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441BZ	Child	DSH	STANFORD HEALTH CARE	Cutaneous Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441C	Child	DSH	STANFORD HOSPITAL & CLINICS	STANFORD POSITIVE CARE CLINIC	351 El Camino Real	Atherton	CA	Terminated
DSH050441CA	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Neuro Oncology	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CB	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Hematology	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CC	Child	DSH	STANFORD HOSPITAL & CLINICS	Cancer Clinic-Gyn Oncology	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CD	Child	DSH	STANFORD HOSPITAL & CLINICS	BMT Clinic-Infusion Treatment Area	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CE	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic-Plastic Surgery-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CF	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Infectious Disease	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441CG	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Infusion Center-Redwood City	900 Blake Wilbur Dr	Stanford	CA	Terminated
DSH050441CH	Child	DSH	STANFORD HEALTH CARE	Concierge Clinic	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CJ	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Stanford Executive Medicine	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CK	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Immunology-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CL	Child	DSH	STANFORD HEALTH CARE	OB/GYN Clinic	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441CM	Child	DSH	STANFORD HOSPITAL & CLINICS	CV Surgery Clinic-Cardiothoracic Surgery-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CN	Child	DSH	STANFORD HOSPITAL & CLINICS	Electrocardiology-ECG-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CP	Child	DSH	STANFORD HOSPITAL & CLINICS	Electrocardiology-ECHO-BW	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CQ	Child	DSH	STANFORD HOSPITAL & CLINICS	Electrocardiology-Cardiovascular Medicine	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441CR	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic-OP CTR Dermatology	960 N San Antonio Rd	Los Altos	CA	Terminated
DSH050441CS	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Surgery	440 Broadway St	Redwood City	CA	Terminated
DSH050441CT	Child	DSH	STANFORD HEALTH CARE	Pain Management	450 Broadway St	Redwood City	CA	Active
DSH050441CU	Child	DSH	STANFORD HEALTH CARE	Dermatology Medicine	440 Broadway St	Redwood City	CA	Active
DSH050441CV	Child	DSH	STANFORD HOSPITAL & CLINICS	Infectious Disease-OPC	450 Broadway St	Redwood City	CA	Terminated
DSH050441CW	Child	DSH	STANFORD HEALTH CARE	Neuro at Hoover	211 Quarry Rd	Palo Alto	CA	Active
DSH050441CX	Child	DSH	STANFORD HEALTH CARE	SNHC Infusion Treatment Center	213 Quarry Road	Palo Alto	CA	Active
DSH050441CY	Child	DSH	STANFORD HEALTH CARE	SNHC Neurology	213 Quarry Road	Palo Alto	CA	Active
DSH050441CZ	Child	DSH	STANFORD HEALTH CARE	Cath Angio Pre-Proced & Recov	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441D	Child	DSH	STANFORD HOSPITAL & CLINICS	ARRILLAGA SPORTS CENTER / Sports Medicine	341 Galvez St	Stanford	CA	Terminated
DSH050441DA	Child	DSH	STANFORD HEALTH CARE	SNHC Neurosurgery	213 Quarry Road	Palo Alto	CA	Active
DSH050441DB	Child	DSH	STANFORD HEALTH CARE	Uro Oncology Facility 3001014	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DC	Child	DSH	STANFORD HEALTH CARE	8002501 - South Bay Cancer Ctr Infusion	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DE	Child	DSH	STANFORD HEALTH CARE	Lane Surgery Center 7101000	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DF	Child	DSH	STANFORD HEALTH CARE	General Radiology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DG	Child	DSH	STANFORD HEALTH CARE	OP CTR Foot and Ankle	420 Broadway St	Redwood City	CA	Active
DSH050441DH	Child	DSH	STANFORD HEALTH CARE	OP CTR Spine	420 Broadway St	Redwood City	CA	Active
DSH050441DJ	Child	DSH	STANFORD HEALTH CARE	OP CTR Hand/Upper and Shoulder/Elbow	450 Broadway St	Redwood City	CA	Active
DSH050441DK	Child	DSH	STANFORD HEALTH CARE	OP CTR Boswell Joint Replacement	450 Broadway St	Redwood City	CA	Active
DSH050441DL	Child	DSH	STANFORD HEALTH CARE	OP CTR Shultz Orthopedics	420 Broadway St	Redwood City	CA	Active
DSH050441DM	Child	DSH	STANFORD HEALTH CARE	OP CTR Sleep	440 Broadway St	Redwood City	CA	Terminated
DSH050441DN	Child	DSH	STANFORD HEALTH CARE	OP CTR Wound Care	440 Broadway St	Redwood City	CA	Active
DSH050441DP	Child	DSH	STANFORD HEALTH CARE	South Bay MRI	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DQ	Child	DSH	STANFORD HEALTH CARE	South Bay CT	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DR	Child	DSH	STANFORD HEALTH CARE	South Bay Ultrasound	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DS	Child	DSH	STANFORD HEALTH CARE	South Bay Radiation Therapy	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DT	Child	DSH	STANFORD HEALTH CARE	South Bay Mammography, Radiology	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DU	Child	DSH	STANFORD HEALTH CARE	South Bay Cancer Center - Clinic 3	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DV	Child	DSH	STANFORD HEALTH CARE	South Bay Cancer Center - Clinic 4	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DW	Child	DSH	STANFORD HEALTH CARE	South Bay Oncology Surgery	2589 Samaritan Drive	San Jose	CA	Active
DSH050441DX	Child	DSH	STANFORD HEALTH CARE	Ultrasound	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DY	Child	DSH	STANFORD HEALTH CARE	Mammography	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441DZ	Child	DSH	STANFORD HEALTH CARE	CT	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441E	Child	DSH	STANFORD HOSPITAL & CLINICS	Ophthalmology Clinic	2453 Watson Court	Palo Alto	CA	Terminated
DSH050441EA	Child	DSH	STANFORD HEALTH CARE	MRI	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EB	Child	DSH	STANFORD HEALTH CARE	OP CTR-LIVER CLINIC	420 Broadway St	Redwood City	CA	Active
DSH050441EC	Child	DSH	STANFORD HEALTH CARE	Sleep Clinic	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441ED	Child	DSH	STANFORD HEALTH CARE	General Surgery	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EE	Child	DSH	STANFORD HEALTH CARE	BW Anti-Coag	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441EF	Child	DSH	STANFORD HEALTH CARE	Head Neck Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EG	Child	DSH	STANFORD HEALTH CARE	BW Cyberknife	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EH	Child	DSH	STANFORD HEALTH CARE	CCSB Nuclear Medicine	2589 Samaritan Drive	San Jose	CA	Active
DSH050441EJ	Child	DSH	STANFORD HEALTH CARE	CCSB Pain Management	2589 Samaritan Drive	San Jose	CA	Active
DSH050441EK	Child	DSH	STANFORD HEALTH CARE	SNHC Cyberknife	213 Quarry Rd.	Palo Alto	CA	Terminated
DSH050441EL	Child	DSH	STANFORD HEALTH CARE	Radiation Oncology WCC	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EM	Child	DSH	STANFORD HEALTH CARE	SNHC General Radiology	213 Quarry Road	Palo Alto	CA	Active
DSH050441EN	Child	DSH	STANFORD HEALTH CARE	Thoracic Oncology - Thoracic Oncology	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441EP	Child	DSH	STANFORD HEALTH CARE	EHC - Urology - Urology Clinic	5800 Hollis St.	Emeryville	CA	Terminated
DSH050441EQ	Child	DSH	STANFORD HEALTH CARE	EHC - PACU - Surgery Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441ER	Child	DSH	STANFORD HEALTH CARE	EHC - CT - Radiology-Diagnostic	5800 Hollis St.	Emeryville	CA	Active
DSH050441ES	Child	DSH	STANFORD HEALTH CARE	EHC-MULTISPCIALTY CLIN II TECH - Emeryville Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441ET	Child	DSH	STANFORD HEALTH CARE	EHC - PULMONARY FUNCTN TESTING - PULMONARY FUNCTION TESTING	5800 Hollis St.	Emeryville	CA	Active
DSH050441EU	Child	DSH	STANFORD HEALTH CARE	EHC - PULMONARY FUNCTION TESTING ( Lab) - PULMONARY FUNCTION TESTING	5800 Hollis St.	Emeryville	CA	Terminated
DSH050441EV	Child	DSH	STANFORD HEALTH CARE	EHC-MULTISPECIALTY CLIN I TECH - Emeryville Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441EW	Child	DSH	STANFORD HEALTH CARE	EHC - PRE ANESTHESIA CLINIC - Anesthesiology	5800 Hollis St.	Emeryville	CA	Terminated
DSH050441EX	Child	DSH	STANFORD HEALTH CARE	EHC - OR - Surgery Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441EY	Child	DSH	STANFORD HEALTH CARE	EHC - MRI	5800 Hollis St.	Emeryville	CA	Active
DSH050441EZ	Child	DSH	STANFORD HEALTH CARE	EHC - CARDIOVASCULAR TESTING - Catheterization	5800 Hollis St.	Emeryville	CA	Active
DSH050441F	Child	DSH	STANFORD HEALTH CARE	STANFORD PRIMARY CARE-PORTOLA VALLEY	3240 Alpine Road	Portola Valley	CA	Terminated
DSH050441FA	Child	DSH	STANFORD HEALTH CARE	EHC - MAMMOGRAPHY - Radiology-Diagnostic	5800 Hollis St.	Emeryville	CA	Active
DSH050441FB	Child	DSH	STANFORD HEALTH CARE	OP CTR DIAGNOSTIC RADIOLOGY PR - Radiology-Diagnostic	440 Broadway St	Redwood City	CA	Active
DSH050441FC	Child	DSH	STANFORD HEALTH CARE	OP Pelvic health Center - Clinic	420 Broadway St	Redwood City	CA	Active
DSH050441FD	Child	DSH	STANFORD HEALTH CARE	EHC - NUCLEAR MEDICINE - Radioisotope	5800 Hollis St.	Emeryville	CA	Active
DSH050441FE	Child	DSH	STANFORD HEALTH CARE	EHC - NEURODIAGNOSTIC LAB - Electroencephalography	5800 Hollis St.	Emeryville	CA	Active
DSH050441FF	Child	DSH	STANFORD HEALTH CARE	EHC - ULTRASOUND - Radiology-Diagnostic	5800 Hollis St.	Emeryville	CA	Active
DSH050441FG	Child	DSH	STANFORD HEALTH CARE	BL WILBUR MULTISPECIALTY CLIN CCSB LIV - Clinic	2589 Samaritan Drive	San Jose	CA	Active
DSH050441FH	Child	DSH	STANFORD HEALTH CARE	IMMUNOLOGY DERM - OC - Clinic	440 Broadway St	Redwood City	CA	Active
DSH050441FJ	Child	DSH	STANFORD HEALTH CARE	Immunology Clinic	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441FK	Child	DSH	STANFORD HEALTH CARE	IMMUNOLOGY ORTHO - OC - Clinic	450 Broadway St	Redwood City	CA	Active
DSH050441FL	Child	DSH	STANFORD HEALTH CARE	Infectious Diseases Hoover	211 Quarry Rd	Palo Alto	CA	Active
DSH050441FM	Child	DSH	STANFORD HEALTH CARE	Endocrinology Clinic	211 Quarry Rd	Palo Alto	CA	Active
DSH050441FN	Child	DSH	STANFORD HEALTH CARE	BW DIGESTIVE HEALTH CENTER CCSB DHC - SURG - Surgery Clinic	2589 Samaritan Drive	San Jose	CA	Active
DSH050441FP	Child	DSH	STANFORD HEALTH CARE	MSPECIALTY PORTOLA VALLEY - TECH - Clinic	3240 Alpine Road	Portola Valley	CA	Terminated
DSH050441FQ	Child	DSH	STANFORD HEALTH CARE	Gynecology Clinic OPC - Gynecology	420 Broadway St	Redwood City	CA	Active
DSH050441FR	Child	DSH	STANFORD HEALTH CARE	ORTHOPAEDIC TRAUMA - ORTHOPEDICS	450 Broadway St	Redwood City	CA	Active
DSH050441FS	Child	DSH	STANFORD HEALTH CARE	Endocrine Oncology	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441FT	Child	DSH	STANFORD HEALTH CARE	DHC /GEN SURGERY TECH BILLING -DIGESTIVE HEALTH RWC - Surgery Clinic	420 Broadway St	Redwood City	CA	Active
DSH050441FU	Child	DSH	STANFORD HEALTH CARE	Blood and Marrow Transplant	900 Blake Wilbur Dr	Palo Alto	CA	Terminated
DSH050441FV	Child	DSH	STANFORD HEALTH CARE	EMERGENCY SERVICES - EMERGENCY	500 Pasteur Drive	Stanford	CA	Terminated
DSH050441FW	Child	DSH	STANFORD HEALTH CARE	SNHC CT Scan	213 Quarry Road	Palo Alto	CA	Active
DSH050441FX	Child	DSH	STANFORD HEALTH CARE	EHC CANCER CLINIC - Cancer Clinic	5800 Hollis St.	Emeryville	CA	Active
DSH050441FY	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR CT PAV D	420 Broadway St	Redwood City	CA	Active
DSH050441FZ	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR CT PAV B	440 Broadway St	Redwood City	CA	Active
DSH050441G	Child	DSH	STANFORD HOSPITAL & CLINICS	STANFORD MEDICINE OUTPATIENT CENTER / Dermatology Clinic	440 Broadway Street	Redwood City	CA	Terminated
DSH050441GA	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR PRE ANESTHESIA PAV D	420 Broadway St	Redwood City	CA	Active
DSH050441GB	Child	DSH	STANFORD HEALTH CARE	SNHC Ortho	213 Quarry Road	Palo Alto	CA	Active
DSH050441GC	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR ENDOSCOPY OR	420 Broadway St	Redwood City	CA	Active
DSH050441GD	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR ORTHO PMR AND SPORTS MEDICINE	450 Broadway St	Redwood City	CA	Active
DSH050441GE	Child	DSH	STANFORD HEALTH CARE	SNHC MRI	213 Quarry Road	Palo Alto	CA	Active
DSH050441GG	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - OP CTR MRI PAV B	440 Broadway St	Redwood City	CA	Active
DSH050441GH	Child	DSH	STANFORD HEALTH CARE	Lane Surgery Pre/Post Care - Surgery Clinic	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441GJ	Child	DSH	STANFORD HEALTH CARE	BW MRI - MRI	875 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441GK	Child	DSH	STANFORD HEALTH CARE	BYERS PRE ANESTHESIA CLINIC - Anesthesiology	2452 Watson Court	Palo Alto	CA	Active
DSH050441GL	Child	DSH	STANFORD HEALTH CARE	Cancer Clinic-Neurosurgery - Neurosurgery	875 Blake Wibur Dr	Palo Alto	CA	Active
DSH050441GM	Child	DSH	STANFORD HEALTH CARE	EHC - Infusion Treatment Center	5800 Hollis St.	Emeryville	CA	Active
DSH050441GN	Child	DSH	STANFORD HEALTH CARE	STANFORD HEALTH CARE - CCSB Palliative Medicine	2589 SAMARITAN DR	SAN JOSE	CA	Active
DSH050441GP	Child	DSH	STANFORD HEALTH CARE	CANCER CLINIC REDWOOD CITY - CANCER CLINIC	440 Broadway Street	Redwood City	CA	Active
DSH050441GQ	Child	DSH	STANFORD HEALTH CARE	BLOOD AND MARROW TRANSPLANT CLINIC - HEMATOLOGY	875 Blake Wilbur Drive	Palo Alto	CA	Active
DSH050441GR	Child	DSH	STANFORD HEALTH CARE	WALK-IN CLINIC - EMERGENCY	211 Quarry Rd	Palo Alto	CA	Active
DSH050441GS	Child	DSH	STANFORD HEALTH CARE	OTOLARYNGOLOGY SNHC - OTOLARYNGOLOGY SNHC	213 Quarry Road	Palo Alto	CA	Active
DSH050441H	Child	DSH	STANFORD HEALTH CARE	ENT Clinic / ENT/Surgery	801 Welch Rd	Palo Alto	CA	Active
DSH050441J	Child	DSH	STANFORD HEALTH CARE	EYE INSTITUTE AT STANFORD	2452 Watson Ct	Palo Alto	CA	Active
DSH050441K	Child	DSH	STANFORD HEALTH CARE	Surgery Clinic - Plastics	1000 Welch Rd	Palo Alto	CA	Active
DSH050441L	Child	DSH	STANFORD HEALTH CARE	Sarcoma	900 Blake Wilbur Dr	Palo Alto	CA	Active
DSH050441M	Child	DSH	STANFORD HEALTH CARE	OP CTR Multispeciality Dermatology-Phototherapy	440 Broadway St	Redwood City	CA	Active
DSH050441N	Child	DSH	STANFORD HEALTH CARE	Urology Clinic	1000 Welch Rd	Palo Alto	CA	Active
DSH050441P	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic	100A San Pablo Towne Center	San Pablo	CA	Terminated
DSH050441Q	Child	DSH	STANFORD HOSPITAL & CLINICS	Pain Services	100A San Pablo Towne Center	San Pablo	CA	Terminated
DSH050441R	Child	DSH	STANFORD HOSPITAL & CLINICS	Dermatology Clinic	1555 Soquel Dr	Santa Cruz	CA	Terminated
DSH050441S	Child	DSH	STANFORD HOSPITAL & CLINICS	Radiology-Diagnostic	16400 Lark Ave	Los Gatos	CA	Terminated
DSH050441T	Child	DSH	STANFORD HOSPITAL & CLINICS	LOS GATOS NEUROSURGERY	16400 LARK AVE	LOS GATOS	CA	Terminated
DSH050441U	Child	DSH	STANFORD HEALTH CARE	Dermatology Clinic	211 Quarry Rd	Palo Alto	CA	Active
DSH050441V	Child	DSH	STANFORD HEALTH CARE	Senior Care	211 Quarry Rd	Palo Alto	CA	Active
DSH050441W	Child	DSH	STANFORD HEALTH CARE	Internal Medicine	211 Quarry Rd	Palo Alto	CA	Active
DSH050441X	Child	DSH	STANFORD HOSPITAL & CLINICS	Clinic-Stanford Coordinated Care	211 Quarry Rd	Palo Alto	CA	Terminated
DSH050441Y	Child	DSH	STANFORD HEALTH CARE	Express Care Clinic	211 Quarry Rd	Palo Alto	CA	Active
DSH050441Z	Child	DSH	STANFORD HEALTH CARE	Family Medicine	211 Quarry Rd	Palo Alto	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Change Request	7100590750 (KY)		3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		635477	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000177684	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		131360026	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200105830C	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500400133	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1026297	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (FL)		3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (KY)		3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (TX)		3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (IL)		3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/12/2025 2:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/12/2025 2:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/12/2025 2:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/12/2025 2:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/12/2025 2:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/12/2025 2:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	3/12/2025 2:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/12/2025 2:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	3/12/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500400133 (OR)		12/13/2024 2:07 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9000177684 (CO)		12/13/2024 2:07 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1026297 (UT)		12/13/2024 2:07 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2098468 (WA)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (OR)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (CO)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (GA)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (UT)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (CT)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NY)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (WA)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (WY)		12/13/2024 2:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/13/2024 2:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	12/13/2024 2:07 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	635477 (AZ)		9/13/2024 12:07 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9205328 (MS)		9/13/2024 12:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2024 12:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100590750	9/13/2024 12:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	9/13/2024 12:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2024 12:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1026297	9/13/2024 12:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	9/13/2024 12:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2024 12:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2098468	9/13/2024 12:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (AZ)		9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (AR)		9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MS)		9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NJ)		9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (VT)		9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2024 12:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2024 12:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2024 12:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2024 12:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2024 12:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	9/13/2024 12:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2024 12:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		WY	9/13/2024 12:07 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 1:06:41 PM	8/20/2024 1:57:29 PM	8/20/2024 1:57 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	533259 (HI)		6/12/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000A0561 (NM)		6/12/2024 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9205328	6/12/2024 12:57 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (HI)		6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (WY)		6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (TX)		6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (WA)		6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NM)		6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (AL)		6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MO)		6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	6/12/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	6/12/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	807248900 (ID)		3/13/2024 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/13/2024 12:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000A0561	3/13/2024 12:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (FL)		3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (ID)		3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (IN)		3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (OH)		3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (OK)		3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/13/2024 12:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/13/2024 12:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/13/2024 12:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	3/13/2024 12:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/13/2024 12:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	3/13/2024 12:55 PM
Contacts	Primary Contact	Update	Change Request	Fry, Benjamin Senior Manager - 340B Program Stanford Health Care 6503041319	Lopez, Muang 340B Business Analyst Stanford Health Care 7076881874	12/15/2023 2:06 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100643860E (KS)		12/13/2023 1:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9205328 (MS)		12/13/2023 1:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2023 1:28 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		807248900	12/13/2023 1:28 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (KS)		12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (LA)		12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MS)		12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/13/2023 1:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/13/2023 1:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/13/2023 1:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/13/2023 1:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/13/2023 1:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/13/2023 1:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/13/2023 1:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/13/2023 1:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	12/13/2023 1:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1026297 (UT)		9/13/2023 8:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2023 8:35 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000177684	9/13/2023 8:35 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	9/13/2023 8:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2023 8:35 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100643860E	9/13/2023 8:35 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	9/13/2023 8:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2023 8:35 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9205328	9/13/2023 8:35 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (AR)		9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (IL)		9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NC)		9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (TX)		9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (UT)		9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (VA)		9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2023 8:35 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2023 8:35 PM
Medicaid Billing	NPI: State	Insert	Change Request		KS	9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2023 8:35 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	9/13/2023 8:35 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/13/2023 8:35 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	9/13/2023 8:35 PM
Addresses	Shipping Address	Delete	Recertification	Stanford Neuroscience Health Center Pharmacy 213 Quarry Road Room #2726 Stanford, CA 94305		8/29/2023 1:06 PM
Addresses	Shipping Address	Delete	Recertification	Stanford Healthcare Pharmacy 420 Broadway Street Redwood City, CA 94063		8/29/2023 1:06 PM
Addresses	Shipping Address	Insert	Recertification		Stanford Neuroscience Health Center Pharmacy 213 Quarry Road Room 2726 Palo Alto, CA 94304	8/29/2023 1:06 PM
Details	Last Recertification Date	Update	Recertification	9/2/2022 8:17:15 PM	8/29/2023 1:06:41 PM	8/29/2023 1:06 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9000177684 (CO)		6/12/2023 6:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000A0561 (NM)		6/12/2023 6:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2023 6:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1026297	6/12/2023 6:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (CO)		6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (LA)		6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NM)		6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (TN)		6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2023 6:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2023 6:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2023 6:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2023 6:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2023 6:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2023 6:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	6/12/2023 6:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/12/2023 6:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		WY	6/12/2023 6:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	807248900 (ID)		3/10/2023 1:01 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1026297 (UT)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (ID)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (OK)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (IL)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (UT)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (AK)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MA)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (VT)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (WY)		3/10/2023 1:01 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/10/2023 1:01 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	3/10/2023 1:01 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	116853300 (OH)		12/12/2022 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2022 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		533259	12/12/2022 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		HI	12/12/2022 12:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2022 12:24 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000A0561	12/12/2022 12:24 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MI)		12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NC)		12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MD)		12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MN)		12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (OH)		12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (TX)		12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/12/2022 12:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		AK	12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/12/2022 12:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/12/2022 12:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		HI	12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/12/2022 12:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/12/2022 12:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/12/2022 12:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/12/2022 12:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		VT	12/12/2022 12:24 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/12/2022 12:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		WY	12/12/2022 12:24 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9049530 (FL)		9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500400133	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		635477	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000177684	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		116853300	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1026297	9/9/2022 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (IN)		9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (FL)		9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (HI)		9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MA)		9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NY)		9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/9/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/9/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/9/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/9/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/9/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/9/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/9/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	9/9/2022 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	9/9/2022 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	9/9/2022 2:22 PM
Details	Last Recertification Date	Update	Recertification	8/19/2021 4:20:48 PM	9/2/2022 8:17:15 PM	9/2/2022 8:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	940057626 (CO)		6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000A0561 (NM)		6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	635477 (AZ)		6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	116853300 (WY)		6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9049530	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		807248900	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1288115	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (CO)		6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NM)		6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (AZ)		6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NH)		6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (WY)		6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/13/2022 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/13/2022 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		HI	6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/13/2022 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/13/2022 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/13/2022 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/13/2022 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/13/2022 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	6/13/2022 5:17 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/13/2022 5:17 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	6/13/2022 5:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500400133 (OR)		3/11/2022 3:41 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	244848 (HI)		3/11/2022 3:41 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	807248900 (ID)		3/11/2022 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/11/2022 3:41 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		635477	3/11/2022 3:41 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	3/11/2022 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/11/2022 3:41 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		116853300	3/11/2022 3:41 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WY	3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (OR)		3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (ID)		3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (KY)		3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (GA)		3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (HI)		3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (MA)		3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/11/2022 3:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/11/2022 3:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/11/2022 3:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/11/2022 3:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	3/11/2022 3:41 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/11/2022 3:41 PM
Medicaid Billing	NPI: State	Insert	Change Request		WY	3/11/2022 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		940057626	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		244848	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		HI	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		807248900	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000A0561	12/9/2021 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	12/9/2021 3:32 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NV)		12/9/2021 3:32 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (IL)		12/9/2021 3:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/9/2021 3:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	12/9/2021 3:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/9/2021 3:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	12/9/2021 3:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/9/2021 3:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		HI	12/9/2021 3:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/9/2021 3:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	12/9/2021 3:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/9/2021 3:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	12/9/2021 3:32 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/9/2021 3:32 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	12/9/2021 3:32 PM
Details	Last Recertification Date	Update	Recertification	9/11/2020 8:18:49 AM	8/19/2021 4:20:48 PM	8/19/2021 4:20 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	635477 (AZ)		6/10/2021 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	9000177684 (CO)		6/10/2021 2:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/10/2021 2:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500400133	6/10/2021 2:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (AZ)		6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (WY)		6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NJ)		6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (CO)		6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NY)		6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (CT)		6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/10/2021 2:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/10/2021 2:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/10/2021 2:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	6/10/2021 2:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	6/10/2021 2:08 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	90495300 (FL)		3/10/2021 5:26 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2098468 (WA)		3/10/2021 5:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/10/2021 5:26 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		635477	3/10/2021 5:26 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	3/10/2021 5:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/10/2021 5:26 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000177684	3/10/2021 5:26 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (FL)		3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (WA)		3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (UT)		3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NM)		3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (TN)		3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/10/2021 5:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/10/2021 5:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		WY	3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/10/2021 5:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/10/2021 5:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/10/2021 5:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/10/2021 5:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	3/10/2021 5:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	3/10/2021 5:26 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	3/10/2021 5:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 4:48 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		90495300	12/10/2020 4:48 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	12/10/2020 4:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/10/2020 4:48 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2098468	12/10/2020 4:48 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	12/10/2020 4:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/10/2020 4:48 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	12/10/2020 4:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/10/2020 4:48 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	12/10/2020 4:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/10/2020 4:48 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	12/10/2020 4:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/10/2020 4:48 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	12/10/2020 4:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/10/2020 4:48 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	12/10/2020 4:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871543215	12/10/2020 4:48 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	12/10/2020 4:48 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (NV)		9/11/2020 12:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	90495300 (FL)		9/11/2020 12:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (AR)		9/11/2020 12:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (CT)		9/11/2020 12:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (ID)		9/11/2020 12:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (IL)		9/11/2020 12:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (OH)		9/11/2020 12:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500400133 (OR)		9/11/2020 12:42 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (TX)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (FL)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (OR)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (TX)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (OH)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (IL)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (ID)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (CT)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (AR)		9/11/2020 12:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871543215 (NV)		9/11/2020 12:42 PM
Addresses	Shipping Address	Insert	Recertification		Stanford Health Care - (Redwood Outpatient Clinic Pharmacy) 450 Broadway St. Pavillion B, 3rd FL L030823 Redwood City, CA 94063	9/11/2020 8:18 AM
Addresses	Shipping Address	Insert	Recertification		Stanford Emeryville Health Center Pharmacy 5800 Hollis Street Room 2325 Emeryville, CA 94608	9/11/2020 8:18 AM
Addresses	Shipping Address	Insert	Recertification		Stanford Health Care Pharmacy 875 Blake Wilbur Dr STE CC1102 Palo Alto, CA 94305	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1871543215 ( )		9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1053835595	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1871543215	9/11/2020 8:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/11/2020 8:18 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1053835595 ( )		9/11/2020 8:18 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 6:20:11 PM	9/11/2020 8:18:49 AM	9/11/2020 8:18 AM
Addresses	Shipping Address	Delete	Recertification	Stanford Health Care Pharmacy 875 Blake Wilbur Dr STE CC1102 Palo Alto, CA 94304		9/11/2020 8:18 AM
Addresses	Shipping Address	Delete	Recertification	Stanford Health Care - (Redwood Outpatien Clinic Pharmacy) 450 Broadway St. Pavillion B, 3rd FL L030823 Redwood City, CA 94063		9/11/2020 8:18 AM
Addresses	Shipping Address	Delete	Recertification	Stanford Emeryville Health Center Pharma 5800 Hollis Street Room 2325 Emeryville, CA 94608		9/11/2020 8:18 AM
Addresses	Shipping Address	Delete	Change Request	Stanford Health Care Pharmacy 875 Blake Wilbur Dr STE CC1102 Palo Alto, CA 94305		6/15/2020 2:07 PM
Addresses	Shipping Address	Insert	Change Request		Stanford Health Care Pharmacy 875 Blake Wilbur Dr STE CC1102 Palo Alto, CA 94304	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		90495300	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500400133	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	6/15/2020 2:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	6/15/2020 2:07 PM
Contacts	Primary Contact	Update	Change Request	Sinnadurai, Sinthusan Director Stanford health care 6502859974	Fry, Benjamin Senior Manager - 340B Program Stanford Health Care 6503041319	3/23/2020 7:01 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1053835595 (GA)		3/12/2020 5:21 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (CT)		3/12/2020 5:21 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	533259 (HI)		3/12/2020 5:21 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (NJ)		3/12/2020 5:21 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (PA)		3/12/2020 5:21 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (TX)		3/12/2020 5:21 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1871543215 (UT)		3/12/2020 5:21 PM
Addresses	Shipping Address	Insert	Change Request		Stanford Health Care, 500P Hospital 500 Pasteur Dr. Stanford, CA 94305-1048	3/10/2020 8:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		533259	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		HI	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1871543215	12/12/2019 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	12/12/2019 11:10 AM
Contacts	Primary Contact	Update	Change Request	Chellamy, Caroline Assistant Director of Pharmacy Services Stanford Health Care 6507247812	Sinnadurai, Sinthusan Director Stanford health care 6502859974	10/30/2019 9:53 AM
Details	Last Recertification Date	Update	Recertification	9/11/2018 4:30:57 PM	9/3/2019 6:20:11 PM	9/3/2019 6:20 PM
Addresses	Shipping Address	Insert	Change Request		Stanford Healthcare Pharmacy 420 Broadway Street Redwood City, CA 94063	7/10/2019 3:14 PM
Addresses	Shipping Address	Delete	Change Request	Stanford Health Care Pharmacy - (ITA Cancer Center) 875 Blake Wilbur CC 2308 Stanford, CA 94305		4/4/2019 11:17 AM
Addresses	Shipping Address	Insert	Change Request		Stanford Health Care Pharmacy - (ITA Cancer Center) 875 Blake Wilbur DR RM CC 2308 Palo Alto, CA 94304	4/4/2019 11:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/28/2018 11:53 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1053835595	9/28/2018 11:53 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	9/28/2018 11:53 AM
Addresses	Billing Address	Insert	Recertification		Stanford Health Care 300 Pasteur Drive Stanford, CA 94305	9/11/2018 4:30 PM
Addresses	Shipping Address	Insert	Recertification		Stanford Health Care Pavillion C-1 Pharmacy 450 Broadway RM L011102 Redwood City, CA 94063	9/11/2018 4:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSC00441H (NY)		9/11/2018 4:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSC00441H (TX)		9/11/2018 4:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSC00441H (MS)		9/11/2018 4:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSC00441H (MT)		9/11/2018 4:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSC00441H (NM)		9/11/2018 4:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSC00441H (OR)		9/11/2018 4:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSC00441H (UT)		9/11/2018 4:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1053835595	9/11/2018 4:30 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 8:16:19 AM	9/11/2018 4:30:57 PM	9/11/2018 4:30 PM
Addresses	Shipping Address	Insert	Change Request		Stanford Emeryville Health Center Pharma 5800 Hollis Street Room 2325 Emeryville, CA 94608	8/7/2018 12:39 PM
Addresses	Shipping Address	Insert	Recertification		Stanford Health Care - (Redwood Outpatien Clinic Pharmacy) 450 Broadway St. Pavillion B, 3rd FL L030823 Redwood City, CA 94063	12/5/2017 8:16 AM
Addresses	Shipping Address	Insert	Recertification		Stanford Health Care Pharmacy - (ITA Cancer Center) 875 Blake Wilbur CC 2308 Stanford, CA 94305	12/5/2017 8:16 AM
Addresses	Shipping Address	Insert	Recertification		Stanford Health Care - (Central Pharmacy) 300 Pasteur Drive RM H0301 Stanford, CA 94305	12/5/2017 8:16 AM
Addresses	Shipping Address	Insert	Recertification		Stanford South Bay Cancer Center Pharmacy 2589 Samaritan Drive RM# 4205 San Jose, CA 95124	12/5/2017 8:16 AM
Addresses	Shipping Address	Insert	Recertification		Stanford Health Care - (Outpatient Center Pharmacy) 450 Broadway Street Pavilion A 3rd Floor L030225 Redwood City, CA 94063	12/5/2017 8:16 AM
Addresses	Shipping Address	Insert	Recertification		Stanford Neuroscience Health Center Pharmacy 213 Quarry Road Room #2726 Stanford, CA 94305	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC00441H	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC00441H	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC00441H	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC00441H	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MT	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC00441H	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC00441H	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSC00441H	12/5/2017 8:16 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		UT	12/5/2017 8:16 AM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	12/5/2017 8:16:19 AM	12/5/2017 8:16 AM
Contacts	Authorizing Official	Update		Hoff, Linda CFO 6504970391	Hoff, Linda CFO Stanford Health Care 6504970391	9/29/2017 12:38 PM
Contacts	Primary Contact	Update		Chellamy, Caroline Assistant Director of Pharmacy Services 6507247812	Chellamy, Caroline Assistant Director of Pharmacy Services Stanford Health Care 6507247812	9/18/2017 4:52 PM
Contacts	Authorizing Official	Insert			Hoff, Linda CFO 6504970391	8/3/2017 7:24 AM
Contacts	Primary Contact	Update		Sisodiya, Deepak Director of Pharmacy Services 6507255801	Chellamy, Caroline Assistant Director of Pharmacy Services 6507247812	8/3/2017 7:24 AM
Contacts	Signed By	Insert			Morissette, Daniel CFO 6507369776	8/3/2017 7:24 AM
Addresses	Shipping Address	Delete		Stanford Health Care Central Pharmacy 300 Pasteur Drive RM H0301 Stanford, CA 94305		8/1/2017 3:35 PM
Addresses	Shipping Address	Delete		Stanford Health Care Outpatient Center Pharmacy 450 Broadway Street Pavilion A 3rd Floor L030225 Redwood City, CA 94063		8/1/2017 3:35 PM
Addresses	Shipping Address	Delete		Stanford Health Care Redwood Outpatient Clinic Pharmacy 450 Broadway Street Pavilion B 3rd Floor L030823 Redwood City, CA 94063		8/1/2017 3:35 PM
Addresses	Shipping Address	Delete		Stanford Health Care South Bay Cancer Center Department of Pharmacy 2589 Samaritan Drive RM# 4205 RM# 4205 San Jose, CA 95124		8/1/2017 3:35 PM
Addresses	Shipping Address	Delete		Stanford Health Care Neuroscience Health Center Pharmacy 213 Quarry Road Room #2726 Stanford, CA 94305		8/1/2017 3:35 PM
Addresses	Shipping Address	Delete		ITA Cancer Center Pharmacy 875 Blake Wilbur CC 2308 Palo Alto, CA 94305		8/1/2017 3:35 PM
Addresses	Main Address	Insert			300 PASTEUR DRIVE Stanford, CA 94305	8/1/2017 3:35 PM
Addresses	Shipping Address	Insert			Stanford Health Care Central Pharmacy 300 Pasteur Drive RM H0301 Stanford, CA 94305	8/1/2017 3:35 PM
Addresses	Shipping Address	Insert			Stanford Health Care Outpatient Center Pharmacy 450 Broadway Street Pavilion A 3rd Floor L030225 Redwood City, CA 94063	8/1/2017 3:35 PM
Addresses	Shipping Address	Insert			Stanford Health Care Redwood Outpatient Clinic Pharmacy 450 Broadway Street Pavilion B 3rd Floor L030823 Redwood City, CA 94063	8/1/2017 3:35 PM
Addresses	Shipping Address	Insert			Stanford Health Care South Bay Cancer Center Department of Pharmacy 2589 Samaritan Drive RM# 4205 RM# 4205 San Jose, CA 95124	8/1/2017 3:35 PM
Addresses	Shipping Address	Insert			Stanford Health Care Neuroscience Health Center Pharmacy 213 Quarry Road Room #2726 Stanford, CA 94305	8/1/2017 3:35 PM
Addresses	Shipping Address	Insert			ITA Cancer Center Pharmacy 875 Blake Wilbur CC 2308 Palo Alto, CA 94305	8/1/2017 3:35 PM
Addresses	Shipping Address	Insert			Stanford Health Care Pharmacy 875 Blake Wilbur Dr STE CC1102 Palo Alto, CA 94305	8/1/2017 3:35 PM
Details	Entity Name	Update		STANFORD HOSPITAL & CLINICS	STANFORD HEALTH CARE	8/1/2017 3:35 PM
Contacts	Primary Contact	Insert			Sisodiya, Deepak Director of Pharmacy Services 6507255801	12/7/2016 7:50 AM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 7:36 PM
Details	Last Recertification Date	Update			8/31/2015 12:00:00 AM	8/31/2015 8:55 PM
Dates	Participating Approval Date	Update			5/13/2015 12:00:00 AM	5/13/2015 2:37 PM
Details	State	Update		Pending	Active	5/13/2015 2:37 PM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/13/2015 2:37 PM
Details	340B ID	Update		ONLINE_REG_50907	DSH050441	4/14/2015 9:33 AM
Details	340B ID	Update			ONLINE_REG_50907	4/8/2015 6:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/8/2015 6:38 PM
Medicaid Billing	Medicaid: Number	Insert			HSC00441H	4/8/2015 6:38 PM
Medicaid Billing	Medicaid: State	Insert			CA	4/8/2015 6:38 PM
Medicaid Billing	NPI: Number	Insert			1871543215	4/8/2015 6:38 PM
Details	Last Recertification Date	Insert				4/8/2015 6:38 PM
Details	Grant Number	Insert				4/8/2015 6:38 PM
Details	340B ID	Insert				4/8/2015 6:38 PM
Details	Is Authorizing Official EHB Data	Insert				4/8/2015 6:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/8/2015 6:38 PM
Details	Medicare Provider Number	Insert			050441	4/8/2015 6:38 PM
Details	Entity Name	Insert			STANFORD HOSPITAL & CLINICS	4/8/2015 6:38 PM
Details	Program Code	Insert			DSH	4/8/2015 6:38 PM
Details	Entity Subname	Insert				4/8/2015 6:38 PM
Dates	Participating Approval Date	Insert				4/8/2015 6:38 PM
Details	State	Insert			Pending	4/8/2015 6:38 PM
Dates	Registration Date	Insert			4/8/2015 12:00:00 AM	4/8/2015 6:38 PM
Dates	Signed By Date	Insert			4/8/2015 12:00:00 AM	4/8/2015 6:38 PM
Dates	Start Date	Insert				4/8/2015 6:38 PM
Terminations	Termination Comments	Insert				4/8/2015 6:38 PM
Terminations	Termination Date	Insert				4/8/2015 6:38 PM
Terminations	Termination Effective Date	Insert				4/8/2015 6:38 PM
Terminations	Termination Reason	Insert				4/8/2015 6:38 PM