Covered Entity Details

DSH050360 MARIN GENERAL HOSPITAL (Active) - information as of 6/12/2025 9:45:21 PM

Main Details

Name

MARIN GENERAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050360

Medicare Provider Number

050360

Additional Details

Current Program Status

Active

Registration Date

4/14/2016

Participating Start Date

7/1/2016

Participating Approval Date

6/2/2016

Last Recertification Date

9/10/2024

Contacts

Authorizing Official

Marin General Hospital
Elizabeth Lasnier, Controller
(415) 925-7449

Primary Contact

Marin General Hospital
Megan Engler, 340B Coordinator
(415) 328-1454

Addresses

Street Address

250 BON AIR ROAD
GREENBRAE, CA 94904

Billing Address
Same as Street Address

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
CA	MSM003606	1396725677

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/19/2020	01/01/2021		01/01/2021
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/19/2020	01/01/2021		01/01/2021
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/19/2020	01/01/2021		01/01/2021
Contract Detail	BIOPLUS SPECIALTY INFUSION CA, LLC	19110 VAN NESS AVE.		TORRANCE	CA	90501	01/11/2019	04/01/2019	09/13/2019	09/13/2019
Contract Detail	BIOPLUS SPECIALTY INFUSION TX, LLC	1748 N GREENVILLE AVE		RICHARDSON	TX	75081	01/11/2019	04/01/2019	09/13/2019	09/13/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY CA	7373 LINCOLN WAY		GARDEN GROVE	CA	92841	01/11/2019	04/01/2019	09/13/2019	09/13/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	01/11/2019	04/01/2019	09/13/2019	09/13/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	01/11/2019	04/01/2019	09/13/2019	09/13/2019
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/07/2021	01/01/2022		01/01/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/07/2021	01/01/2022		01/01/2022
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/14/2020	01/01/2021		01/01/2021
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/19/2020	01/01/2021		01/01/2021
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA CVS/PHARMACY # 1483	1599 TIBURON BLVD	TIBURON	CA	94920	01/15/2020	04/01/2020		04/01/2020
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 04952	909 GRAND ST.	SAN RAFAEL	CA	94901	01/15/2020	04/01/2020	10/14/2024	10/15/2024
Contract Detail	KROGER SPECIALTY PHARMACY CA 2	6240 WILSHIRE BLVD.		LOS ANGELES	CA	90048	01/11/2019	04/01/2019	09/13/2019	09/13/2019
Contract Detail	KROGER SPECIALTY PHARMACY FL 2	6435 HAZELTINE NATIONAL DR STE 140		ORLANDO	FL	32822-5156	01/11/2019	04/01/2019	09/13/2019	09/13/2019
Contract Detail	KROGER SPECIALTY PHARMACY INC	KROGER SPECIALTY PHARMACY CA 3	1821 KAISER AVE	IRVINE	CA	92614-5707	01/11/2019	04/01/2019	09/13/2019	09/13/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09219	330 BON AIR SHOPPING CTR	GREENBRAE	CA	94904	01/13/2017	04/01/2017		01/13/2017
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09811	1871 EL CAMINO REAL	BURLINGAME	CA	94010	01/13/2017	04/01/2017	09/30/2018	09/30/2018
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09152	201 W NAPA ST STE 35	SONOMA	CA	95476	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09214	1558 TRANCAS ST	NAPA	CA	94558	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09216	60 CABRILLO HWY N	HALF MOON BAY	CA	94019	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09250	885 ISLAND DR STE A	ALAMEDA	CA	94502	10/11/2018	01/01/2019	10/03/2022	10/19/2022
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09316	1707 GRANT AVE	NOVATO	CA	94945	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09480	365 E WASHINGTON ST	PETALUMA	CA	94952	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09529	442 LAS GALLINAS AVE	SAN RAFAEL	CA	94903	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09554	77 BOVET RD	SAN MATEO	CA	94402	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09656	2771 4TH ST	SANTA ROSA	CA	95405	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09752	375 GELLERT BLVD	DALY CITY	CA	94015	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09807	10 BAYHILL SHOPPING CTR	SAN BRUNO	CA	94066	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09833	4242 S EL CAMINO REAL	SAN MATEO	CA	94403	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09872	6877 SEBASTOPOL AVENUE	SEBASTOPOL	CA	95472	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09879	987 E HILLSDALE BLVD	FOSTER CITY	CA	94404	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09904	3667 CASTRO VALLEY BLVD	CASTRO VALLEY	CA	94546	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09913	759 E BLITHEDALE AVE	MILL VALLEY	CA	94941	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09940	872 N DELAWARE ST	SAN MATEO	CA	94401	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09946	463 STONY POINT RD	SANTA ROSA	CA	95401	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09947	2035 NOVATO BLVD	NOVATO	CA	94947	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09957	344 THOMAS L. BERKLEY WAY	OAKLAND	CA	94612	10/11/2018	01/01/2019	10/14/2024	10/15/2024
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09962	150 DONAHUE ST	SAUSALITO	CA	94965	10/11/2018	01/01/2019	10/14/2024	10/15/2024
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09977	124 DE ANZA BLVD	SAN MATEO	CA	94402	10/11/2018	01/01/2019		01/01/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09370	880 SIR FRANCIS DRAKE BLVD	SAN ANSELMO	CA	94960	01/15/2020	04/01/2020		04/01/2020
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	10/14/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	10/15/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/15/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/14/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	10/14/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	10/14/2020	01/01/2021	06/18/2021	10/07/2021
Contract Detail	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	10/14/2020	01/01/2021	10/14/2024	10/15/2024
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/14/2020	01/01/2021		01/01/2021
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/15/2020	04/01/2020		04/01/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY	445 CASTRO STREET	SAN FRANCISCO	CA	94114	01/15/2020	04/01/2020	10/14/2024	10/15/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/07/2021	01/01/2022		01/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	10/07/2021	01/01/2022		01/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/07/2021	01/01/2022		01/01/2022
Contract Detail	WELLPARTNER, INC	20800 SW 115TH AVE	SUITE 100	TUALATIN	OR	97062	01/13/2017	04/01/2017	07/04/2018	05/31/2019

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050360A	Child	DSH	MARIN GENERAL HOSPITAL	RADIATION ONCOLOGY	1350 S. ELISEO DR	GREENBRAE	CA	Terminated
DSH050360B	Child	DSH	MARIN GENERAL HOSPITAL	Marin Outpatient Imaging Center	1240 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360C	Child	DSH	MARIN GENERAL HOSPITAL	Eliseo Vascular Testing	1100 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360D	Child	DSH	MARIN GENERAL HOSPITAL	BRADEN DIABETES CENTER	1100 S ELISEO DR 2	GREENBRAE	CA	Terminated
DSH050360E	Child	DSH	MARIN GENERAL HOSPITAL	Breast Center	1240 S Eliseo Dr	Greenbrae	CA	Terminated
DSH050360F	Child	DSH	MARIN GENERAL HOSPITAL	75 Rowland Vascular and Cardiovascular Testing	75 Rowland Way	Novato	CA	Terminated
DSH050360G	Child	DSH	MARIN GENERAL HOSPITAL	2 Bon Air Cardiovascular Testing	2 Bon Air Rd	Greenbrae	CA	Terminated
DSH050360H	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT PHYSICAL THERAPY - MARINHEALTH OUTPATIENT PHYSICAL THERAPY	1350 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360J	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH VASCULAR MEDICINE	75 ROWLAND WAY	NOVATO	CA	Active
DSH050360K	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH CARDIOVASCULAR MEDICINE	2 BON AIR ROAD	LARKSPUR	CA	Active
DSH050360L	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH UROLOGY	1240 SOUTH ELISEO DRIVE	GREENBRAE	CA	Active
DSH050360M	Child	DSH	MARIN GENERAL HOSPITAL	BREAST HEALTH CENTER - MARINHEALTH BREAST HEALTH CENTER	100A DRAKES LANDING RD	GREENBRAE	CA	Terminated
DSH050360N	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - IMAGING	1240 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360P	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT MRI	1260 SOUTH ELISEO DRIVE	GREENBRAE	CA	Active
DSH050360Q	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH CARDIOVASCULAR MEDICINE - MARINHEALTH CARDIOVASCULAR MEDICINE	75 ROWLAND WAY	NOVATO	CA	Terminated
DSH050360R	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH BRADEN DIABETES CENTER - BRADEN DIABETES CENTER	1100 SOUTH ELISEO DRIVE	GREENBRAE	CA	Terminated
DSH050360S	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - OUTPATIENT MRI	75 Rowland Way	NOVATO	CA	Terminated
DSH050360T	Child	DSH	MARIN GENERAL HOSPITAL	MARINHEALTH OUTPATIENT IMAGING CENTER - OUTPATIENT MRI	2 BON AIR ROAD	LARKSPUR	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 1:59:54 PM	9/10/2024 8:04:26 AM	9/10/2024 8:04 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 8:16:34 AM	8/29/2023 1:59:54 PM	8/29/2023 1:59 PM
Contacts	Primary Contact	Update	Profile Change Request	Engler, Megan 340B Coordinator Marin General Hospital 4159257130	Engler, Megan 340B Coordinator Marin General Hospital 4153281454	7/24/2023 2:33 PM
Details	Last Recertification Date	Update	Recertification	9/13/2021 7:08:21 AM	8/30/2022 8:16:34 AM	8/30/2022 8:16 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 11:41:52 AM	9/13/2021 7:08:21 AM	9/13/2021 7:08 AM
Contacts	Primary Contact	Update	Profile Change Request	Engler, Megan Pharmacy Buyer / 340B Coordinator Marin General Hospital 4159257130	Engler, Megan 340B Coordinator Marin General Hospital 4159257130	5/18/2021 9:23 AM
Contacts	Primary Contact	Update	Change Request	Helser, Therese Director, Pharmacy Marin General Hospital 4159257867	Engler, Megan Pharmacy Buyer / 340B Coordinator Marin General Hospital 4159257130	4/26/2021 12:31 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1396725677 (CA)		8/27/2020 11:41 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1396725677	8/27/2020 11:41 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/27/2020 11:41 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1396725677 ( )		8/27/2020 11:41 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 8:43:10 PM	8/27/2020 11:41:52 AM	8/27/2020 11:41 AM
Contacts	Authorizing Official	Update	Change Request	Eckhart, Megan Marie 340B Coordinator Marin General Hospital 4159257884	Lasnier, Elizabeth Controller Marin General Hospital 4159257449	1/15/2020 12:41 PM
Contacts	Authorizing Official	Update	AO Change Request	Wells, Beverly Assistant Controller MarinHealth 4159257437	Eckhart, Megan Marie 340B Coordinator Marin General Hospital 4159257884	12/16/2019 8:07 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 8:53:38 AM	8/21/2019 8:43:10 PM	8/21/2019 8:43 PM
Contacts	Authorizing Official	Update	Change Request	Noonan, Jean Controller Marin General Hospital 4159257449	Wells, Beverly Assistant Controller MarinHealth 4159257437	8/8/2019 7:17 AM
Contacts	Authorizing Official	Update	Change Request	McManus, James Chief Financial Officer Marin General Hospital 4159252095	Noonan, Jean Controller Marin General Hospital 4159257449	4/3/2019 3:23 PM
Contacts	Primary Contact	Update	Recertification	Sillman, Michael Director of Pharmacy Marin General Hospital 4159257867	Helser, Therese Director, Pharmacy Marin General Hospital 4159257867	8/22/2018 8:53 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 3:38:06 PM	8/22/2018 8:53:38 AM	8/22/2018 8:53 AM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/15/2017 3:38:06 PM	11/15/2017 3:38 PM
Contacts	Authorizing Official	Update		McManus, James Chief Financial Officer 4159252095	McManus, James Chief Financial Officer Marin General Hospital 4159252095	10/9/2017 9:07 PM
Contacts	Signed By	Update		McManus, James Chief Financial Officer 4159252095	McManus, James Chief Financial Officer Marin General Hospital 4159252095	10/9/2017 9:07 PM
Contacts	Primary Contact	Update		Sillman, Michael Director of Pharmacy 4159257867	Sillman, Michael Director of Pharmacy Marin General Hospital 4159257867	9/28/2017 12:52 PM
Contacts	Authorizing Official	Insert			McManus, James Chief Financial Officer 4159252095	1/13/2017 3:25 PM
Contacts	Signed By	Insert			McManus, James Chief Financial Officer 4159252095	1/13/2017 3:25 PM
Contacts	Primary Contact	Insert			Sillman, Michael Director of Pharmacy 4159257867	10/20/2016 2:49 PM
Addresses	Main Address	Insert			250 BON AIR ROAD GREENBRAE, CA 94904	8/24/2016 3:59 PM
Details	Last Recertification Date	Update			8/24/2016 12:00:00 AM	8/24/2016 3:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/2/2016 12:22 PM
Medicaid Billing	Medicaid: Number	Insert			1396725677	6/2/2016 12:22 PM
Medicaid Billing	Medicaid: State	Insert			CA	6/2/2016 12:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/2/2016 12:22 PM
Medicaid Billing	Medicaid: Number	Insert			MSM003606	6/2/2016 12:22 PM
Medicaid Billing	Medicaid: State	Insert			CA	6/2/2016 12:22 PM
Medicaid Billing	NPI: Number	Insert			1396725677	6/2/2016 12:22 PM
Dates	Last Date That 340B Drugs Purchased	Update		3/31/2016 12:00:00 AM		6/2/2016 12:22 PM
Dates	Participating Approval Date	Update		2/18/2016 12:00:00 AM	6/2/2016 12:00:00 AM	6/2/2016 12:22 PM
Details	State	Update		Terminated	Active	6/2/2016 12:22 PM
Dates	Registration Date	Update		1/13/2016 12:00:00 AM	4/14/2016 12:00:00 AM	6/2/2016 12:22 PM
Dates	Signed By Date	Update		1/13/2016 12:00:00 AM	4/14/2016 12:00:00 AM	6/2/2016 12:22 PM
Dates	Start Date	Update		4/1/2016 12:00:00 AM	7/1/2016 12:00:00 AM	6/2/2016 12:22 PM
Terminations	Termination Comments	Update		3/31/16 OPA terminated based on review of termination request that was submitted on 3/31/16 but not yet "accepted" by the AO		6/2/2016 12:22 PM
Terminations	Termination Date	Update		4/1/2016 12:00:00 AM		6/2/2016 12:22 PM
Terminations	Termination Effective Date	Update		4/1/2016 12:00:00 AM		6/2/2016 12:22 PM
Terminations	Termination Reason	Update		Other		6/2/2016 12:22 PM
Dates	Last Date That 340B Drugs Purchased	Update			3/31/2016 12:00:00 AM	3/31/2016 10:42 PM
Details	State	Update		Active	Terminated	3/31/2016 10:42 PM
Terminations	Termination Comments	Update			3/31/16 OPA terminated based on review of termination request that was submitted on 3/31/16 but not yet "accepted" by the AO	3/31/2016 10:42 PM
Terminations	Termination Date	Update			4/1/2016 12:00:00 AM	3/31/2016 10:42 PM
Terminations	Termination Effective Date	Update			4/1/2016 12:00:00 AM	3/31/2016 10:42 PM
Terminations	Termination Reason	Update			Other	3/31/2016 10:42 PM
Dates	Participating Approval Date	Update			2/18/2016 12:00:00 AM	2/18/2016 2:09 PM
Details	State	Update		Pending	Active	2/18/2016 2:09 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	2/18/2016 2:09 PM
Details	340B ID	Update		DEL-DSH050360	DSH050360	2/8/2016 1:57 PM
Details	State	Update		Rejected	Pending	2/8/2016 1:57 PM
Details	340B ID	Update		DSH050360	DEL-DSH050360	2/1/2016 8:53 AM
Details	State	Update		Pending	Rejected	2/1/2016 8:53 AM
Details	340B ID	Update		DSH050360L	DSH050360	1/29/2016 11:43 AM
Details	340B ID	Update		ONLINE_REG_57740	DSH050360L	1/29/2016 11:40 AM
Details	340B ID	Update			ONLINE_REG_57740	1/13/2016 5:52 PM
Details	Last Recertification Date	Insert				1/13/2016 5:52 PM
Details	Grant Number	Insert				1/13/2016 5:52 PM
Details	340B ID	Insert				1/13/2016 5:52 PM
Details	Is Authorizing Official EHB Data	Insert				1/13/2016 5:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/13/2016 5:52 PM
Details	Medicare Provider Number	Insert			050360	1/13/2016 5:52 PM
Details	Entity Name	Insert			MARIN GENERAL HOSPITAL	1/13/2016 5:52 PM
Details	Program Code	Insert			DSH	1/13/2016 5:52 PM
Details	Entity Subname	Insert				1/13/2016 5:52 PM
Dates	Participating Approval Date	Insert				1/13/2016 5:52 PM
Details	State	Insert			Pending	1/13/2016 5:52 PM
Dates	Registration Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 5:52 PM
Dates	Signed By Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 5:52 PM
Dates	Start Date	Insert				1/13/2016 5:52 PM
Terminations	Termination Comments	Insert				1/13/2016 5:52 PM
Terminations	Termination Date	Insert				1/13/2016 5:52 PM
Terminations	Termination Effective Date	Insert				1/13/2016 5:52 PM
Terminations	Termination Reason	Insert				1/13/2016 5:52 PM