| Details | Last Recertification Date | Update | Recertification | 1/31/2024 12:45:44 PM | 3/3/2025 12:00:08 PM | 3/3/2025 12:00 PM |
| Details | Last Recertification Date | Update | Recertification | 2/21/2023 8:47:48 AM | 1/31/2024 12:45:44 PM | 1/31/2024 12:45 PM |
| Contacts | Primary Contact | Update | Group Change Request | Farrage, Mark E.
Interim Pharmacy Director
Charles Drew Health Center, Inc.
4028109816 | Cherney, Mark A
Senior Director of Pharmacy Services
Charles Drew Health Center, Inc.
4028109909 | 8/30/2023 9:47 AM |
| Contacts | Primary Contact | Update | Group Change Request | Tate, Wayne L
Sr. Director of Pharmacy Services
Charles Drew Health Center, Inc.
4028109806 | Farrage, Mark E.
Interim Pharmacy Director
Charles Drew Health Center, Inc.
4028109816 | 7/21/2023 5:36 PM |
| Details | Last Recertification Date | Update | Recertification | 2/14/2022 9:22:34 AM | 2/21/2023 8:47:48 AM | 2/21/2023 8:47 AM |
| Details | Last Recertification Date | Update | Recertification | 2/28/2021 1:53:17 PM | 2/14/2022 9:22:34 AM | 2/14/2022 9:22 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/28/2021 1:53 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 10026276412 | 2/28/2021 1:53 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | NE | 2/28/2021 1:53 PM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 470666715-40 (NE) | | 2/28/2021 1:53 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1255302170 ( ) | | 2/28/2021 1:53 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1871962944 | 2/28/2021 1:53 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | NE | 2/28/2021 1:53 PM |
| Details | Last Recertification Date | Update | Recertification | 2/4/2020 11:09:22 AM | 2/28/2021 1:53:17 PM | 2/28/2021 1:53 PM |
| Details | Is Authorizing Official EHB Data | Update | Recertification | False | | 2/28/2021 1:53 PM |
| Details | Last Recertification Date | Update | Recertification | 2/14/2019 11:08:47 AM | 2/4/2020 11:09:22 AM | 2/4/2020 11:09 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2018 2:43:04 PM | 2/14/2019 11:08:47 AM | 2/14/2019 11:08 AM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2017 12:00:00 AM | 2/13/2018 2:43:04 PM | 2/13/2018 2:43 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 | | |
2915 Grant Street
Omaha, NE 68111-3863 | 2/13/2017 11:48 AM |
| Details | Last Recertification Date | Update | | | 2/13/2017 12:00:00 AM | 2/13/2017 11:47 AM |
| Details | Entity Subname | Update | | Charles Drew HC Dental Mobile Unit | Charles Drew Health Center Inc. Dental Mobile Unit - Tooth Mobile | 6/2/2016 1:29 PM |
| Dates | Participating Approval Date | Update | | | 4/15/2016 12:00:00 AM | 4/15/2016 11:01 AM |
| Details | State | Update | | Pending | Active | 4/15/2016 11:01 AM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 4/15/2016 11:01 AM |
| Details | 340B ID | Update | | ONLINE_REG_60140 | CH072110P | 4/15/2016 9:07 AM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_60140 | 4/13/2016 4:46 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/13/2016 4:46 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 470666715-40 | 4/13/2016 4:46 PM |
| Medicaid Billing | Medicaid: State | Insert | | | NE | 4/13/2016 4:46 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1255302170 | 4/13/2016 4:46 PM |
| Details | Last Recertification Date | Insert | | | | 4/13/2016 4:46 PM |
| Details | Grant Number | Insert | | | H80CS00438 | 4/13/2016 4:46 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 4/13/2016 4:46 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 4/13/2016 4:46 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/13/2016 4:46 PM |
| Details | Medicare Provider Number | Insert | | | | 4/13/2016 4:46 PM |
| Details | Entity Name | Insert | | | CHARLES DREW HEALTH CENTER INC | 4/13/2016 4:46 PM |
| Details | Program Code | Insert | | | CH | 4/13/2016 4:46 PM |
| Details | Entity Subname | Insert | | | Charles Drew HC Dental Mobile Unit | 4/13/2016 4:46 PM |
| Dates | Participating Approval Date | Insert | | | | 4/13/2016 4:46 PM |
| Details | State | Insert | | | Pending | 4/13/2016 4:46 PM |
| Dates | Registration Date | Insert | | | 4/13/2016 12:00:00 AM | 4/13/2016 4:46 PM |
| Dates | Signed By Date | Insert | | | 4/13/2016 12:00:00 AM | 4/13/2016 4:46 PM |
| Dates | Start Date | Insert | | | | 4/13/2016 4:46 PM |
| Terminations | Termination Comments | Insert | | | | 4/13/2016 4:46 PM |
| Terminations | Termination Date | Insert | | | | 4/13/2016 4:46 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/13/2016 4:46 PM |
| Terminations | Termination Reason | Insert | | | | 4/13/2016 4:46 PM |