| Dates | Last Date That 340B Drugs Purchased | Update | OPA Edit Termination Info | 8/21/2020 12:00:00 AM | 7/22/2020 12:00:00 AM | 7/15/2021 7:57 AM |
| Details | State | Update | | To Be Terminated | Terminated | 4/1/2021 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 8/21/2020 12:00:00 AM | 2/28/2021 8:42 PM |
| Details | State | Update | Recertification | Active | To Be Terminated | 2/28/2021 8:42 PM |
| Terminations | Termination Date | Update | Recertification | | 4/1/2021 12:00:00 AM | 2/28/2021 8:42 PM |
| Terminations | Termination Effective Date | Update | Recertification | | 7/23/2020 12:00:00 AM | 2/28/2021 8:42 PM |
| Terminations | Termination Reason | Update | Recertification | | Site closure | 2/28/2021 8:42 PM |
| Details | Last Recertification Date | Update | Recertification | 2/14/2019 11:07:41 AM | 2/4/2020 11:08:03 AM | 2/4/2020 11:08 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2018 2:37:44 PM | 2/14/2019 11:07:41 AM | 2/14/2019 11:07 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2017 12:00:00 AM | 2/13/2018 2:37:44 PM | 2/13/2018 2:37 PM |
| Medicaid Billing | Medicaid: Number | Update | Change Request | 1002627864-01 | 100262764-01 | 10/3/2017 3:14 PM |
| Details | Is Authorizing Official EHB Data | Update | Change Request | False | | 10/3/2017 3:14 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Mcmorris, Kenny
Chief Excutive Officer
Charles Drew Health Center, Inc.
4024571245 | McMorris, Kenny D.
Chief Executive Officer
Charles Drew Health Center, Inc.
4024571245 | 10/3/2017 3:08 PM |
| Contacts | Signed By | Update | Profile Change Request | Mcmorris, Kenny
Chief Excutive Officer
Charles Drew Health Center, Inc.
4024571245 | McMorris, Kenny D.
Chief Executive Officer
Charles Drew Health Center, Inc.
4024571245 | 10/3/2017 3:08 PM |
| Contacts | Authorizing Official | Update | | Mcmorris, Kenny
Chief Excutive Officer
4024571245 | Mcmorris, Kenny
Chief Excutive Officer
Charles Drew Health Center, Inc.
4024571245 | 10/3/2017 3:03 PM |
| Contacts | Signed By | Update | | Mcmorris, Kenny
Chief Excutive Officer
4024571245 | Mcmorris, Kenny
Chief Excutive Officer
Charles Drew Health Center, Inc.
4024571245 | 10/3/2017 3:03 PM |
| Contacts | Primary Contact | Update | | Tate, Wayne
Sr. Director of Pharmacy Services
4028109806 | Tate, Wayne L
Sr. Director of Pharmacy Services
Charles Drew Health Center, Inc.
4028109806 | 10/2/2017 1:06 PM |
| Contacts | Authorizing Official | Insert | | | Mcmorris, Kenny
Chief Excutive Officer
4024571245 | 7/12/2017 2:03 PM |
| Contacts | Signed By | Insert | | | Mcmorris, Kenny
Chief Excutive Officer
4024571245 | 7/12/2017 2:03 PM |
| Contacts | Primary Contact | Insert | | | Tate, Wayne
Sr. Director of Pharmacy Services
4028109806 | 5/11/2017 12:39 PM |
| Addresses | Main Address | Insert | | |
4320 Fort Street
Omaha, NE 68111-1849 | 2/13/2017 11:47 AM |
| Details | Last Recertification Date | Update | | | 2/13/2017 12:00:00 AM | 2/13/2017 11:47 AM |
| Addresses | Billing Address | Insert | | | Charles Drew Health Center, Inc.
2915 Grant St.
Omaha, NE 68111 | 6/2/2016 1:25 PM |
| Addresses | Shipping Address | Insert | | | Charles Drew Health Center, Inc.
2915 Grant St
Omaha, NE 68111 | 6/2/2016 1:25 PM |
| Details | Entity Subname | Update | | Charles Drew Health Center at St. Richards | Charles Drew Health Center, Inc. at St. Richards | 6/2/2016 1:25 PM |
| Dates | Participating Approval Date | Update | | | 4/13/2016 12:00:00 AM | 4/13/2016 2:15 PM |
| Details | State | Update | | Pending | Active | 4/13/2016 2:15 PM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 4/13/2016 2:15 PM |
| Details | 340B ID | Update | | ONLINE_REG_59770 | CH072110N | 4/12/2016 3:33 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_59770 | 4/12/2016 11:36 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/12/2016 11:36 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 1002627864-01 | 4/12/2016 11:36 AM |
| Medicaid Billing | Medicaid: State | Insert | | | NE | 4/12/2016 11:36 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1649653551 | 4/12/2016 11:36 AM |
| Details | Last Recertification Date | Insert | | | | 4/12/2016 11:36 AM |
| Details | Grant Number | Insert | | | H80CS00438 | 4/12/2016 11:36 AM |
| Details | 340B ID | Insert | | | ONLINE_REG | 4/12/2016 11:36 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 4/12/2016 11:36 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/12/2016 11:36 AM |
| Details | Medicare Provider Number | Insert | | | | 4/12/2016 11:36 AM |
| Details | Entity Name | Insert | | | CHARLES DREW HEALTH CENTER INC | 4/12/2016 11:36 AM |
| Details | Program Code | Insert | | | CH | 4/12/2016 11:36 AM |
| Details | Entity Subname | Insert | | | Charles Drew Health Center at St. Richards | 4/12/2016 11:36 AM |
| Dates | Participating Approval Date | Insert | | | | 4/12/2016 11:36 AM |
| Details | State | Insert | | | Pending | 4/12/2016 11:36 AM |
| Dates | Registration Date | Insert | | | 4/12/2016 12:00:00 AM | 4/12/2016 11:36 AM |
| Dates | Signed By Date | Insert | | | 4/12/2016 12:00:00 AM | 4/12/2016 11:36 AM |
| Dates | Start Date | Insert | | | | 4/12/2016 11:36 AM |
| Terminations | Termination Comments | Insert | | | | 4/12/2016 11:36 AM |
| Terminations | Termination Date | Insert | | | | 4/12/2016 11:36 AM |
| Terminations | Termination Effective Date | Insert | | | | 4/12/2016 11:36 AM |
| Terminations | Termination Reason | Insert | | | | 4/12/2016 11:36 AM |