Covered Entity Details

DSH050115K PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido) (Terminated) - information as of 4/25/2025 6:34:06 PM

Main Details

Name

PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)

Subdivision Name

Palomar Outpatient Behavioral Health

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050115K

Medicare Provider Number

050115

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/14/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/21/2015

Last Recertification Date

9/4/2015

Termination Date
Termination Reason

7/1/2016
Site closure

Contacts

Authorizing Official

Palomar Health
Carlos A. Bohorquez, Chief FInancial Officer
(760) 740-6385

Primary Contact

Cedric Terrell, AVP Clinical & Diagnostic Services
(760) 739-3932

Addresses

Street Address

125 Vallecitos De Oro, Suite A
San Marcos, CA 92069

Billing Address

Palomar Health
2227 Enterprise St
San Marcos, CA 92029

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?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050115B	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Expresscare- San Elijo Hills (San Marcos)	1571 San Elijo Rd	San Marcos	CA	Terminated
DSH050115C	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Expresscare- Temecula	30530 Rancho California Rd	Temecula	CA	Terminated
DSH050115D	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Expresscare- Escondido	1509 East Valley Parkway	Escondido	CA	Terminated
DSH050115E	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	PHDC Operating Room/ Surgical Platform	555 E. Valley Parkway	Escondido	CA	Terminated
DSH050115F	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Emergency Room	555 E. Valley Parkway	Escondido	CA	Terminated
DSH050115G	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Chemotherapy (Infusion Center)	2125 Citracado Pkwy	Escondido	CA	Active
DSH050115H	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Wound Care	2130 Citracado Parkway Suite 110A	San Escondido	CA	Active
DSH050115J	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Downtown Campus / Behavioral Health Services	555 E. Valley Parkway	Escondido	CA	Terminated
DSH050115K	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Outpatient Behavioral Health	125 Vallecitos De Oro, Suite A	San Marcos	CA	Terminated
DSH050115L	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Downtown Campus / PHDC Radiology Diagnostic	555 E. Valley Parkway	Escondido	CA	Terminated
DSH050115M	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Home Health	120 Craven Road	San Marcos	CA	Active
DSH050115N	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	PMC Escondido - Crisis Stabilization Unit	2185 Citracado Parkway	Escondido	CA	Active
DSH050115P	Child	DSH	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	Palomar Health Radiation Oncology - Radiation Oncology	2125 Citracado Parkway	Escondido	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	AO Change Request	King, Hubert U. Chief Financial Officer Palomar Health 7607406385	Bohorquez, Carlos A. Chief FInancial Officer Palomar Health 7607406385	3/20/2019 8:54 AM
Contacts	Authorizing Official	Update	Profile Change Request	King, Hubert U. Interim Chief Financial Officer Palomar Health 7607406385	King, Hubert U. Chief Financial Officer Palomar Health 7607406385	8/15/2018 6:27 PM
Contacts	Authorizing Official	Update	Change Request	Hansen, Diane Executive VP Finance Palomar Health 7607406385	King, Hubert U. Interim Chief Financial Officer Palomar Health 7607406385	1/11/2018 1:27 PM
Contacts	Authorizing Official	Update		Hansen, Diane Executive VP Finance 7607406385	Hansen, Diane Executive VP Finance Palomar Health 7607406385	10/25/2017 12:00 PM
Contacts	Authorizing Official	Update		Hemker, Robert A. CEO 7607406393	Hansen, Diane Executive VP Finance 7607406385	9/11/2017 3:29 PM
Contacts	Authorizing Official	Insert			Hemker, Robert A. CEO 7607406393	8/1/2017 3:35 PM
Contacts	Signed By	Insert			Hemker, Robert A. CEO 7607406393	8/1/2017 3:35 PM
Addresses	Main Address	Insert			125 Vallecitos De Oro, Suite A San Marcos, CA 92069	6/15/2017 10:47 AM
Addresses	Billing Address	Insert			Palomar Health 2227 Enterprise St San Marcos, CA 92029	6/15/2017 10:47 AM
Contacts	Primary Contact	Insert			Terrell, Cedric AVP Clinical & Diagnostic Services 7607393932	6/15/2017 10:47 AM
Details	Entity Name	Update		PALOMAR MEDICAL CENTER	PALOMAR MEDICAL CENTER ESCONDIDO (PMC Escondido)	6/15/2017 10:47 AM
Dates	Last Date That 340B Drugs Purchased	Update			5/27/2016 12:00:00 AM	6/7/2016 1:47 PM
Details	State	Update		Active	Terminated	6/7/2016 1:47 PM
Terminations	Termination Comments	Update			Medications no longer provided to patients at this site.	6/7/2016 1:47 PM
Terminations	Termination Date	Update			7/1/2016 12:00:00 AM	6/7/2016 1:47 PM
Terminations	Termination Effective Date	Update			5/27/2016 12:00:00 AM	6/7/2016 1:47 PM
Terminations	Termination Reason	Update			Site closure	6/7/2016 1:47 PM
Details	Last Recertification Date	Update			9/4/2015 12:00:00 AM	9/4/2015 11:35 AM
Dates	Participating Approval Date	Update			5/21/2015 12:00:00 AM	5/21/2015 11:44 AM
Details	State	Update		Pending	Active	5/21/2015 11:44 AM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/21/2015 11:44 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_51526	DSH050115K	4/29/2015 1:25 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_51526	4/14/2015 4:41 PM
Details	Last Recertification Date	Insert				4/14/2015 4:41 PM
Details	Grant Number	Insert				4/14/2015 4:41 PM
Details	340B ID	Insert				4/14/2015 4:41 PM
Details	Is Authorizing Official EHB Data	Insert				4/14/2015 4:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/14/2015 4:41 PM
Details	Medicare Provider Number	Insert			050115	4/14/2015 4:41 PM
Details	Entity Name	Insert			PALOMAR MEDICAL CENTER	4/14/2015 4:41 PM
Details	Program Code	Insert			DSH	4/14/2015 4:41 PM
Details	Entity Subname	Insert			Palomar Outpatient Behavioral Health	4/14/2015 4:41 PM
Dates	Participating Approval Date	Insert				4/14/2015 4:41 PM
Details	State	Insert			Pending	4/14/2015 4:41 PM
Dates	Registration Date	Insert			4/14/2015 12:00:00 AM	4/14/2015 4:41 PM
Dates	Signed By Date	Insert			4/14/2015 12:00:00 AM	4/14/2015 4:41 PM
Dates	Start Date	Insert				4/14/2015 4:41 PM
Terminations	Termination Comments	Insert				4/14/2015 4:41 PM
Terminations	Termination Date	Insert				4/14/2015 4:41 PM
Terminations	Termination Effective Date	Insert				4/14/2015 4:41 PM
Terminations	Termination Reason	Insert				4/14/2015 4:41 PM