Covered Entity Details

DSH500088S PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER (Active) - information as of 6/6/2025 12:39:12 PM

Main Details

Name

PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER

Subdivision Name

VMC Specialty Care Clinics - Medication Management Clinic, Covington

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500088S

Medicare Provider Number

500088

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/9/2015

Participating Start Date

1/1/2016

Participating Approval Date

11/4/2015

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Public Hospital District No 1 of King County
Jeannine Grinnell, Chief Executive and Financial Officer
(425) 690-3310

Primary Contact

Public Hospital District No. 1 of King County
Kenneth Kenyon, VP Pharmacy Services
(425) 690-3155

Addresses

Street Address

16850 SE 272nd St
Suite 100
Covington, WA 98042

Billing Address

Public Hospital District No. 1 of King County DBA Valley Medical Center
PO Box 50010
400 South 43rd Street
Renton, WA 98058

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
WA		1649209230

Shipping Addresses

Shipping Address 1

Public Hospital District No. 1 of King County DBA Valley Medical Center
400 South 43rd Street
Renton, WA 98055

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
DSH500088AA	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Covington Diabetes and Education	27500 168th Place SE	Covington	WA	Terminated
DSH500088AB	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Eye Clinic	3915 Talbot Road South	Renton	WA	Terminated
DSH500088AC	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Primary Care Clinics - Senior Care and Internal Medicine Clinic	4033 Talbot Road South	Renton	WA	Active
DSH500088AD	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Medication Management Clinic	4033 Talbot Road South	Renton	WA	Active
DSH500088AE	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - High Risk Genetics	4033 Talbot Road South	Renton	WA	Active
DSH500088AF	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Primary Care Clinics - Valley Women's Healthcare Clinic - Covington	16850 SE 272nd Street	Covington	WA	Active
DSH500088AG	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Urology Clinic	4033 Talbot Road South	Renton	WA	Active
DSH500088AH	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Sports Medicine	3915 Talbot Road South	Renton	WA	Active
DSH500088AJ	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Ear, Nose, and Throat Clinic, Covington	16850 SE 272nd St	Covington	WA	Active
DSH500088AK	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Dermatology, Maple Valley	26458 Maple Valley Black Diamond Rd SE	Maple Valley	WA	Active
DSH500088AL	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Cardiology, Covington	16850 SE 272nd St	Covington	WA	Active
DSH500088AM	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Valley Medical Center - Ambulatory Infusion Center	4009 Talbot Road South	Renton	WA	Active
DSH500088AN	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Valley Medical Center - Rehab Services	400 South 43rd Street	Renton	WA	Active
DSH500088AP	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Valley Medical Center: - Radiation Oncology	400 South 43rd Street	Renton	WA	Active
DSH500088AQ	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics: Rheumatology - Renton	4033 Talbot Road South	Renton	WA	Active
DSH500088AR	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics: - Valley Neuroscience Institute (Adult)	400 South 43rd Street	Renton	WA	Active
DSH500088AS	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - - Allergy and Immunology Clinic, Covington	16850 SE 272nd Street, Suite 100	Covington	WA	Terminated
DSH500088AT	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Pulmonary Clinic, Covington	16850 SE 272nd Street, Suite 100	Covington	WA	Active
DSH500088AU	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - - Diabetes, Thyroid, and Endocrine Clinic	16850 SE 272nd Street, Suite 100	Covington	WA	Active
DSH500088AV	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Infectious Disease Clinic	4033 Talbot Road South	Renton	WA	Active
DSH500088AW	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	- Valley Medical Center - Infusion Center	4009 Talbot Road South	RENTON	WA	Active
DSH500088AX	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - - Child Psychiatry, Covington	27500 168th Place SE	Covington	WA	Active
DSH500088AY	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Urology Clinic, Covington	16850 SE 272nd St	Covington	WA	Active
DSH500088AZ	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC VDI - - PET CT	4033 Talbot Rd South	Renton	WA	Approved
DSH500088B	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Cascade Primary Care Clinic	3915 Talbot Rd South	Renton	WA	Active
DSH500088C	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Covington Primary Care Clinic	27500 168th Place SE	Covington	WA	Active
DSH500088D	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Covington Urgent Care	27500 168th Place SE	Covington	WA	Active
DSH500088E	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Rheumatology Clinic	16850 SE 272nd St	Covington	WA	Active
DSH500088F	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	North Benson Urgent Care	10555 SE Carr Rd	Renton	WA	Terminated
DSH500088G	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Kent Primary Care Clinic	24920 104th Ave SE	Kent	WA	Active
DSH500088H	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Valley Family Medicine	3915 Talbot Road South	Renton	WA	Active
DSH500088J	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Nephrology Clinic	24920 104th Ave SE	Kent	WA	Active
DSH500088K	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Valley Podiatry Clinic	24920 104th Ave SE	Kent	WA	Terminated
DSH500088L	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Diabetes Education	24920 104th Ave SE	Kent	WA	Terminated
DSH500088M	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Correctional Medicine	3915 Talbot Road South	Renton	WA	Terminated
DSH500088N	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Midwives	16850 SE 272nd St	Covington	WA	Terminated
DSH500088P	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Maternal Fetal Medicine	4033 Talbot Road South	Renton	WA	Active
DSH500088Q	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC OP Wound Service	400 South 43rd Street	Renton	WA	Active
DSH500088R	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Endoscopy Center	17820 Talbot Rd South	Renton	WA	Active
DSH500088S	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	VMC Specialty Care Clinics - Medication Management Clinic, Covington	16850 SE 272nd St	Covington	WA	Active
DSH500088T	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Covington South Radiology	27500 168th Place SE	Covington	WA	Active
DSH500088U	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Covington Podiatry	27500 168th Place SE	Covington	WA	Active
DSH500088V	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Olympic Building Imaging	400 South 43rd Street	Renton	WA	Active
DSH500088W	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	The Breast Center	4033 Talbot Road South Suite 470	Renton	WA	Active
DSH500088X	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Maple Valley Primary Care	26458 Maple Valley Black Diamond Rd SE	Maple Valley	WA	Terminated
DSH500088Y	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	Maple Valley Urgent Care	26458 Maple Valley Black Diamond Rd SE	Maple Valley	WA	Active
DSH500088Z	Child	DSH	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	North Benson Podiatry Clinic	10555 SE Carr Road	Renton	WA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Grinnell, Jeannine Chief Financial Officer Public Hospital District No 1 of King County 4252283440-4268	Grinnell, Jeannine Chief Executive and Financial Officer Public Hospital District No 1 of King County 4256903310	8/21/2024 6:42 AM
Details	Last Recertification Date	Update	Recertification	8/25/2023 10:55:43 AM	8/20/2024 5:21:06 PM	8/20/2024 5:21 PM
Contacts	Primary Contact	Update	Profile Change Request	Kenyon, Kenneth VP Pharmacy Services Public Hospital District No. 1 of King County 4256903155-5855	Kenyon, Kenneth VP Pharmacy Services Public Hospital District No. 1 of King County 4256903155	8/1/2024 3:47 PM
Contacts	Primary Contact	Update	Profile Change Request	Kenyon, Kenneth VP Pharmacy Services Public Hospital District No. 1 of King County 4252283440-5855	Kenyon, Kenneth VP Pharmacy Services Public Hospital District No. 1 of King County 4256903155-5855	8/1/2024 3:00 PM
Details	Entity Subname	Update	Change Request	Covington Anticoagulation	VMC Specialty Care Clinics - Medication Management Clinic, Covington	2/16/2024 7:26 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 5:06:17 PM	8/25/2023 10:55:43 AM	8/25/2023 10:55 AM
Details	Last Recertification Date	Update	Recertification	9/2/2021 4:45:09 PM	9/13/2022 5:06:17 PM	9/13/2022 5:06 PM
Contacts	Primary Contact	Update	Profile Change Request	Kenyon, Kenneth Pharmacy Director Public Hospital District No. 1 of King County 4252283440-5855	Kenyon, Kenneth VP Pharmacy Services Public Hospital District No. 1 of King County 4252283440-5855	1/19/2022 4:06 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1006267 (AK)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	23028 (AZ)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	95015509 (CO)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	OP003073963 (CT)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	98520100 (FL)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	934363385A (GA)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	542482 (HI)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	095301 (IA)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1649209230 (ID)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	916000986002 (IL)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1744972 (LA)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1649209230 (ME)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	OP1649209230 (MI)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1649209230 (MN)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	00096897 (MS)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	272688 (MT)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1474466 (ND)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3089737 (NH)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	000B0891 (NM)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1608300 (NY)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	457410 (OH)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100705530A (OK)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	207191 (OR)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1649209230 (RI)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	OP11832B (SC)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	500088 (VT)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	80492600 (WI)		9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	110574400 (WY)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (AL)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (AK)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (AS)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (AZ)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (AR)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (CA)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (CO)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (CT)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (DE)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (DC)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (FM)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (FL)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (GA)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (GU)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (HI)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (ID)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (IL)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (IN)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (IA)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (KS)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (KY)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (LA)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (ME)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MH)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MD)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MA)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MI)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MN)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MS)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MO)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MT)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (NE)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (NV)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (NH)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (NJ)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (NM)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (NY)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (NC)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (ND)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (MP)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (OH)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (OK)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (OR)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (PW)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (PA)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (PR)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (RI)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (SC)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (SD)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (TN)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (TX)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (UT)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (VT)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (VI)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (VA)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (WV)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (WI)		9/2/2021 4:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1649209230 (WY)		9/2/2021 4:45 PM
Details	Last Recertification Date	Update	Recertification	9/11/2020 2:00:37 PM	9/2/2021 4:45:09 PM	9/2/2021 4:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1006267	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		23028	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		95015509	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		OP003073963	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		98520100	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		934363385A	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		542482	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		HI	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		095301	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		916000986002	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1744972	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		OP1649209230	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00096897	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		272688	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MT	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1474466	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ND	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3089737	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NH	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000B0891	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1608300	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		457410	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100705530A	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		207191	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		RI	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		OP11832B	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		500088	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		80492600	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110574400	9/11/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WY	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Update	Recertification		AL	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		AS	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		DC	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		FM	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		GU	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		HI	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		KS	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MH	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NH	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		ND	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MP	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		PW	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		PR	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		RI	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		SD	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		VI	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		WV	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/11/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1649209230	9/11/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	9/11/2020 2:00 PM
Details	Last Recertification Date	Update	Recertification	9/10/2019 1:49:15 PM	9/11/2020 2:00:37 PM	9/11/2020 2:00 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 2:03:04 PM	9/10/2019 1:49:15 PM	9/10/2019 1:49 PM
Addresses	Billing Address	Insert	Recertification		Public Hospital District No. 1 of King County DBA Valley Medical Center PO Box 50010 400 South 43rd Street Renton, WA 98058	8/30/2018 2:03 PM
Addresses	Shipping Address	Insert	Recertification		Public Hospital District No. 1 of King County DBA Valley Medical Center 400 South 43rd Street Renton, WA 98055	8/30/2018 2:03 PM
Addresses	Main Address	Update	Recertification	16850 SE 272nd St Suite 100 Covington, WA 98042	16850 SE 272nd St Suite 100 Covington, WA 98042	8/30/2018 2:03 PM
Details	Last Recertification Date	Update	Recertification	11/16/2017 3:17:20 PM	8/30/2018 2:03:04 PM	8/30/2018 2:03 PM
Details	Last Recertification Date	Update	Recertification	8/23/2016 12:00:00 AM	11/16/2017 3:17:20 PM	11/16/2017 3:17 PM
Contacts	Authorizing Official	Update		Grinnell, Jeannine Chief Financial Officer 4252283440-4268	Grinnell, Jeannine Chief Financial Officer Public Hospital District No 1 of King County 4252283440-4268	10/16/2017 3:03 PM
Contacts	Primary Contact	Update		Kenyon, Kenneth Pharmacy Director 4252283440-5855	Kenyon, Kenneth Pharmacy Director Public Hospital District No. 1 of King County 4252283440-5855	10/3/2017 6:25 PM
Contacts	Signed By	Insert			Smith, Larry SVP Chief Financial Officer 4252283440-5536	8/9/2017 12:30 PM
Contacts	Authorizing Official	Insert			Grinnell, Jeannine Chief Financial Officer 4252283440-4268	6/28/2017 3:55 PM
Contacts	Primary Contact	Insert			Kenyon, Kenneth Pharmacy Director 4252283440-5855	6/19/2017 7:29 AM
Addresses	Main Address	Insert			16850 SE 272nd St Suite 100 Covington, WA 98042	6/19/2017 7:28 AM
Details	Entity Name	Update		VALLEY MEDICAL CENTER	PUBLIC HOSPITAL DISTRICT NO 1 OF KING COUNTY DBA VALLEY MEDICAL CENTER	11/21/2016 8:42 AM
Details	Last Recertification Date	Update			8/23/2016 12:00:00 AM	8/23/2016 12:19 PM
Medicaid Billing	NPI: Number	Insert			1649209230	12/18/2015 9:34 AM
Dates	Participating Approval Date	Update			11/4/2015 12:00:00 AM	11/4/2015 5:08 PM
Details	State	Update		Pending	Active	11/4/2015 5:08 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	11/4/2015 5:08 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_54931	DSH500088S	11/4/2015 9:15 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_54931	10/9/2015 4:25 PM
Details	Last Recertification Date	Insert				10/9/2015 4:25 PM
Details	Grant Number	Insert				10/9/2015 4:25 PM
Details	340B ID	Insert				10/9/2015 4:25 PM
Details	Is Authorizing Official EHB Data	Insert				10/9/2015 4:25 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/9/2015 4:25 PM
Details	Medicare Provider Number	Insert			500088	10/9/2015 4:25 PM
Details	Entity Name	Insert			VALLEY MEDICAL CENTER	10/9/2015 4:25 PM
Details	Program Code	Insert			DSH	10/9/2015 4:25 PM
Details	Entity Subname	Insert			Covington Anticoagulation	10/9/2015 4:25 PM
Dates	Participating Approval Date	Insert				10/9/2015 4:25 PM
Details	State	Insert			Pending	10/9/2015 4:25 PM
Dates	Registration Date	Insert			10/9/2015 12:00:00 AM	10/9/2015 4:25 PM
Dates	Signed By Date	Insert			10/9/2015 12:00:00 AM	10/9/2015 4:25 PM
Dates	Start Date	Insert				10/9/2015 4:25 PM
Terminations	Termination Comments	Insert				10/9/2015 4:25 PM
Terminations	Termination Date	Insert				10/9/2015 4:25 PM
Terminations	Termination Effective Date	Insert				10/9/2015 4:25 PM
Terminations	Termination Reason	Insert				10/9/2015 4:25 PM