| Details | Last Recertification Date | Update | Recertification | 2/12/2024 3:12:46 PM | 2/20/2025 9:08:23 PM | 2/20/2025 9:08 PM |
| Details | Last Recertification Date | Update | Recertification | 3/6/2023 7:14:48 AM | 2/12/2024 3:12:46 PM | 2/12/2024 3:12 PM |
| Details | Last Recertification Date | Update | Recertification | 2/28/2022 10:49:33 AM | 3/6/2023 7:14:48 AM | 3/6/2023 7:14 AM |
| Details | Last Recertification Date | Update | Recertification | 2/24/2021 9:39:53 AM | 2/28/2022 10:49:33 AM | 2/28/2022 10:49 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Patterson, Leah
Chief Nursing Officer
RUHS
9514864665 | Patterson, Leah
Chief Nursing Officer
RUHS
9514867532 | 2/8/2022 4:24 PM |
| Addresses | Shipping Address | Insert | Recertification | | RUHS- Surgical Center Pharmacy
26600 Cactus Avenue
Moreno Valley, CA 92555 | 2/24/2021 9:39 AM |
| Details | Last Recertification Date | Update | Recertification | 2/24/2020 11:16:41 AM | 2/24/2021 9:39:53 AM | 2/24/2021 9:39 AM |
| Contacts | Authorizing Official | Update | Change Request | Boatman, Ronnie
Chief Operating Officer
RUHS
9514864135 | Patterson, Leah
Chief Nursing Officer
RUHS
9514864665 | 1/6/2021 10:19 AM |
| Medicaid Billing | NPI: State | Update | Change Request | | CA | 10/6/2020 2:47 PM |
| Contacts | Authorizing Official | Update | Change Request | Prouty, Greg
Executive Director Clinical and Ancillary Services
RUHS
9514864450 | Boatman, Ronnie
Chief Operating Officer
RUHS
9514864135 | 10/6/2020 2:47 PM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2019 1:43:19 PM | 2/24/2020 11:16:41 AM | 2/24/2020 11:16 AM |
| Addresses | Shipping Address | Delete | Change Request | Riverside County Rubidoux Pharmacy
5256 Mission Blvd
Jurupa Valley, CA 92509 | | 4/12/2019 4:38 PM |
| Details | Last Recertification Date | Update | Recertification | 2/22/2018 1:39:26 PM | 2/5/2019 1:43:19 PM | 2/5/2019 1:43 PM |
| Addresses | Shipping Address | Insert | Change Request | | RUHS - Corona Pharmacy
2813 South Main Street
Corona, CA 92882 | 9/17/2018 6:56 AM |
| Addresses | Shipping Address | Insert | Change Request | | RUHS- MC - Retail Pharmacy
26520 Cactus Avenue
Pharmacy
Moreno Valley, CA 92555 | 5/15/2018 7:42 AM |
| Addresses | Shipping Address | Insert | Change Request | | RUHS- Neighborhood Pharmacy
7140 Indiana Ave
Pharmacy
Riverside, CA 92504 | 5/15/2018 7:42 AM |
| Addresses | Shipping Address | Insert | Change Request | | RUHS- Behavioral Health Retail
9990 County Farm Road
Pharmacy
Riverside, CA 92503 | 5/15/2018 7:42 AM |
| Addresses | Shipping Address | Insert | Change Request | | Riverside County Rubidoux Pharmacy
5256 Mission Blvd
Jurupa Valley, CA 92509 | 5/15/2018 7:42 AM |
| Addresses | Shipping Address | Delete | Change Request | RCRMC OP Pharmacy/County of Riverside
26520 Cactus Avenue
Pharmacy
Moreno Valley, CA 92555 | | 5/15/2018 7:42 AM |
| Addresses | Shipping Address | Delete | Change Request | RCRMC Arlington Pharmacy/County of Riverside
9990 County Farm Road, Suite 2
Pharmacy
Riverside, CA 92503 | | 5/15/2018 7:42 AM |
| Addresses | Shipping Address | Delete | Change Request | Neighborhood Clinic Rx/County of Riverside
7140 Indiana Ave
Pharmacy
Riverside, CA 92504 | | 5/15/2018 7:42 AM |
| Contacts | Authorizing Official | Update | Change Request | Cruikshank, Jennifer
Chief Executive Officer
RUHS
9514864458 | Prouty, Greg
Executive Director Clinical and Ancillary Services
RUHS
9514864450 | 5/15/2018 7:42 AM |
| Contacts | Primary Contact | Update | Change Request | Prouty, Greg
Executive Director Clinical and Ancillary Services
RUHS
9514864450 | Tidwell, Davalyn
Pharmacy Director
RUHS
9514864527 | 5/15/2018 7:42 AM |
| Details | Is Authorizing Official EHB Data | Update | Change Request | False | | 5/15/2018 7:42 AM |
| Details | Last Recertification Date | Update | Recertification | 2/16/2017 12:00:00 AM | 2/22/2018 1:39:26 PM | 2/22/2018 1:39 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Prouty, Greg
Executive Director Clinical and Ancillary Services
RUHS
9514864529 | Prouty, Greg
Executive Director Clinical and Ancillary Services
RUHS
9514864450 | 2/1/2018 3:42 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Cruikshank, Jennifer
Chief Operating Officer
RUHS
9514864458 | Cruikshank, Jennifer
Chief Executive Officer
RUHS
9514864458 | 10/19/2017 1:31 PM |
| Contacts | Signed By | Update | Profile Change Request | Cruikshank, Jennifer
Chief Operating Officer
RUHS
9514864458 | Cruikshank, Jennifer
Chief Executive Officer
RUHS
9514864458 | 10/19/2017 1:31 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Prouty, Greg
Director Pharmacy Services
RUHS
9514864529 | Prouty, Greg
Executive Director Clinical and Ancillary Services
RUHS
9514864529 | 10/19/2017 1:21 PM |
| Contacts | Authorizing Official | Update | | Cruikshank, Jennifer
Chief Operating Officer
9514864458 | Cruikshank, Jennifer
Chief Operating Officer
RUHS
9514864458 | 10/11/2017 5:18 PM |
| Contacts | Signed By | Update | | Cruikshank, Jennifer
Chief Operating Officer
9514864458 | Cruikshank, Jennifer
Chief Operating Officer
RUHS
9514864458 | 10/11/2017 5:18 PM |
| Contacts | Primary Contact | Update | | Prouty, Greg
Director Pharmacy Services
9514864529 | Prouty, Greg
Director Pharmacy Services
RUHS
9514864529 | 9/29/2017 1:12 PM |
| Contacts | Primary Contact | Insert | | | Prouty, Greg
Director Pharmacy Services
9514864529 | 5/24/2017 1:34 PM |
| Contacts | Authorizing Official | Insert | | | Cruikshank, Jennifer
Chief Operating Officer
9514864458 | 5/24/2017 1:34 PM |
| Contacts | Signed By | Insert | | | Cruikshank, Jennifer
Chief Operating Officer
9514864458 | 5/24/2017 1:34 PM |
| Addresses | Main Address | Insert | | |
880 N STATE ST
HEMET, CA 92543-1459 | 2/16/2017 2:09 PM |
| Details | Last Recertification Date | Update | | | 2/16/2017 12:00:00 AM | 2/16/2017 2:09 PM |
| Addresses | Shipping Address | Insert | | | RCRMC OP Pharmacy/County of Riverside
26520 Cactus Avenue
Pharmacy
Moreno Valley, CA 92555 | 3/3/2016 4:05 PM |
| Addresses | Shipping Address | Insert | | | RCRMC Arlington Pharmacy/County of Riverside
9990 County Farm Road, Suite 2
Pharmacy
Riverside, CA 92503 | 3/3/2016 4:05 PM |
| Addresses | Shipping Address | Insert | | | Neighborhood Clinic Rx/County of Riverside
7140 Indiana Ave
Pharmacy
Riverside, CA 92504 | 3/3/2016 4:05 PM |
| Dates | Participating Approval Date | Update | | | 3/3/2016 12:00:00 AM | 3/3/2016 4:05 PM |
| Details | State | Update | | Pending | Active | 3/3/2016 4:05 PM |
| Dates | Start Date | Update | | | 4/1/2016 12:00:00 AM | 3/3/2016 4:05 PM |
| Details | 340B ID | Update | | ONLINE_REG_57042 | CHC28990-03 | 1/12/2016 12:22 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_57042 | 1/11/2016 2:24 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/11/2016 2:24 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | CA-FHC70566F | 1/11/2016 2:24 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 1/11/2016 2:24 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1114031051 | 1/11/2016 2:24 PM |
| Details | Last Recertification Date | Insert | | | | 1/11/2016 2:24 PM |
| Details | Grant Number | Insert | | | H80CS28990 | 1/11/2016 2:24 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 1/11/2016 2:24 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 1/11/2016 2:24 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/11/2016 2:24 PM |
| Details | Medicare Provider Number | Insert | | | | 1/11/2016 2:24 PM |
| Details | Entity Name | Insert | | | RIVERSIDE COUNTY HEALTH SYSTEM | 1/11/2016 2:24 PM |
| Details | Program Code | Insert | | | CH | 1/11/2016 2:24 PM |
| Details | Entity Subname | Insert | | | Hemet Family Care Center | 1/11/2016 2:24 PM |
| Dates | Participating Approval Date | Insert | | | | 1/11/2016 2:24 PM |
| Details | State | Insert | | | Pending | 1/11/2016 2:24 PM |
| Dates | Registration Date | Insert | | | 1/11/2016 12:00:00 AM | 1/11/2016 2:24 PM |
| Dates | Signed By Date | Insert | | | 1/11/2016 12:00:00 AM | 1/11/2016 2:24 PM |
| Dates | Start Date | Insert | | | | 1/11/2016 2:24 PM |
| Terminations | Termination Comments | Insert | | | | 1/11/2016 2:24 PM |
| Terminations | Termination Date | Insert | | | | 1/11/2016 2:24 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/11/2016 2:24 PM |
| Terminations | Termination Reason | Insert | | | | 1/11/2016 2:24 PM |