| Addresses | Main Address | Update | Change Request |
125 Mall Drive
Hanford, CA 93230 |
125 Mall Drive suite 203
Hanford, CA 93230 | 10/8/2024 8:07 AM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2023 1:04:48 PM | 9/3/2024 12:08:53 PM | 9/3/2024 12:08 PM |
| Details | Last Recertification Date | Update | Recertification | 9/19/2022 12:08:52 PM | 9/6/2023 1:04:48 PM | 9/6/2023 1:04 PM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2021 2:28:11 PM | 9/19/2022 12:08:52 PM | 9/19/2022 12:08 PM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2020 8:15:08 PM | 9/1/2021 2:28:11 PM | 9/1/2021 2:28 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 8/24/2020 8:15 PM |
| Details | Last Recertification Date | Update | Recertification | 9/12/2019 12:34:44 AM | 8/24/2020 8:15:08 PM | 8/24/2020 8:15 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2018 3:05:53 PM | 9/12/2019 12:34:44 AM | 9/12/2019 12:34 AM |
| Contacts | Primary Contact | Update | Change Request | Choi, John
Director of Pharmacy
Adventist Medical Center Hanford
5595372204 | Abukhazneh, Ahmed
Pharmacist, Charge
Adventist Health
5595372190 | 7/9/2019 11:41 AM |
| Details | Last Recertification Date | Update | Recertification | 11/29/2017 5:29:49 PM | 8/16/2018 3:05:53 PM | 8/16/2018 3:05 PM |
| Contacts | Authorizing Official | Update | Change Request | Larsen, David L.
SR VP CFO
Adventist Health
5595370050 | Haydock, Timothy Michael
CFO
Adventist Health
5595370050 | 4/3/2018 9:20 AM |
| Details | Last Recertification Date | Update | Recertification | 8/11/2016 12:00:00 AM | 11/29/2017 5:29:49 PM | 11/29/2017 5:29 PM |
| Contacts | Primary Contact | Update | | Choi, John
Director of Pharmacy
5595372204 | Choi, John
Director of Pharmacy
Adventist Medical Center Hanford
5595372204 | 10/27/2017 2:17 PM |
| Contacts | Authorizing Official | Update | | Larsen, David L.
SR VP CFO
5595370050 | Larsen, David L.
SR VP CFO
Adventist Health
5595370050 | 10/26/2017 12:49 PM |
| Contacts | Signed By | Update | | Larsen, David L.
SR VP CFO
5595370050 | Larsen, David L.
SR VP CFO
Adventist Health
5595370050 | 10/26/2017 12:49 PM |
| Contacts | Primary Contact | Update | | Barnes, Steve
VP Finance
5595855550 | Choi, John
Director of Pharmacy
5595372204 | 7/26/2017 2:10 PM |
| Contacts | Authorizing Official | Insert | | | Larsen, David L.
SR VP CFO
5595370050 | 7/18/2017 1:22 PM |
| Contacts | Signed By | Insert | | | Larsen, David L.
SR VP CFO
5595370050 | 7/18/2017 1:22 PM |
| Addresses | Main Address | Insert | | |
125 Mall Drive
Hanford, CA 93230 | 10/18/2016 5:10 PM |
| Addresses | Billing Address | Insert | | | Adventist Medical Center Hanford
115 Mall Drive
Hanford, CA 93230 | 10/18/2016 5:10 PM |
| Addresses | Shipping Address | Insert | | | Adventist Medical Center Hanford
115 Mall Drive
Hanford, CA 93230 | 10/18/2016 5:10 PM |
| Contacts | Primary Contact | Insert | | | Barnes, Steve
VP Finance
5595855550 | 8/16/2016 5:17 PM |
| Details | Last Recertification Date | Update | | 8/31/2015 12:00:00 AM | 8/11/2016 12:00:00 AM | 8/11/2016 1:40 PM |
| Details | Last Recertification Date | Update | | | 8/31/2015 12:00:00 AM | 8/31/2015 9:39 AM |
| Dates | Participating Approval Date | Update | | | 5/14/2015 12:00:00 AM | 5/14/2015 11:53 AM |
| Details | State | Update | | Pending | Active | 5/14/2015 11:53 AM |
| Dates | Start Date | Update | | | 7/1/2015 12:00:00 AM | 5/14/2015 11:53 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_51131 | DSH050121D | 4/14/2015 9:47 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_51131 | 4/10/2015 6:33 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/10/2015 6:33 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | ZZT40121F | 4/10/2015 6:33 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 4/10/2015 6:33 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1538141627 | 4/10/2015 6:33 PM |
| Details | Last Recertification Date | Insert | | | | 4/10/2015 6:33 PM |
| Details | Grant Number | Insert | | | | 4/10/2015 6:33 PM |
| Details | 340B ID | Insert | | | | 4/10/2015 6:33 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/10/2015 6:33 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/10/2015 6:33 PM |
| Details | Medicare Provider Number | Insert | | | 050121 | 4/10/2015 6:33 PM |
| Details | Entity Name | Insert | | | Adventist Medical Center | 4/10/2015 6:33 PM |
| Details | Program Code | Insert | | | DSH | 4/10/2015 6:33 PM |
| Details | Entity Subname | Insert | | | Hanford Medical Pavilion / Breast Care Center - Mammography Services | 4/10/2015 6:33 PM |
| Dates | Participating Approval Date | Insert | | | | 4/10/2015 6:33 PM |
| Details | State | Insert | | | Pending | 4/10/2015 6:33 PM |
| Dates | Registration Date | Insert | | | 4/10/2015 12:00:00 AM | 4/10/2015 6:33 PM |
| Dates | Signed By Date | Insert | | | 4/10/2015 12:00:00 AM | 4/10/2015 6:33 PM |
| Dates | Start Date | Insert | | | | 4/10/2015 6:33 PM |
| Terminations | Termination Comments | Insert | | | | 4/10/2015 6:33 PM |
| Terminations | Termination Date | Insert | | | | 4/10/2015 6:33 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/10/2015 6:33 PM |
| Terminations | Termination Reason | Insert | | | | 4/10/2015 6:33 PM |