| Medicaid Billing | NPI: Number | Insert | Change Request | | 1184429185 | 4/2/2025 11:26 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | CA | 4/2/2025 11:26 AM |
| Contacts | Authorizing Official | Update | Change Request | Loper, Carly
Chief Financial Officer
Pioneers Memorial Healthcare
7603513594 | Loper, Carly
Chief Financial Officer
Pioneers Memorial Hospital
7603513594 | 3/17/2025 9:28 AM |
| Contacts | Primary Contact | Update | Group Change Request | TEAGUE, JOHN P.
DIRECTOR OF PHARMACY
Pioneers Memorial Healthcare District
7603513367 | Teague, John Paul
Director of Pharmacy
Pioneers Memorial Hospital
7603513278 | 3/17/2025 7:52 AM |
| Details | Last Recertification Date | Update | Recertification | 9/5/2023 6:43:46 PM | 8/19/2024 1:42:16 PM | 8/19/2024 1:42 PM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2022 11:43:57 AM | 9/5/2023 6:43:46 PM | 9/5/2023 6:43 PM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2021 2:56:08 PM | 9/6/2022 11:43:57 AM | 9/6/2022 11:43 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Loper, Carly
Chief Financial Officer
Pioneers Memorial Healthcare
7603513954 | Loper, Carly
Chief Financial Officer
Pioneers Memorial Healthcare
7603513594 | 8/25/2021 2:57 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2020 10:27:19 AM | 8/25/2021 2:56:08 PM | 8/25/2021 2:56 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Loper, Carly
Interim CFO
Pioneers Memorial Healthcare
7603513954 | Loper, Carly
Chief Financial Officer
Pioneers Memorial Healthcare
7603513954 | 4/26/2021 7:22 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 9/3/2020 10:27 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2019 7:23:26 PM | 9/3/2020 10:27:19 AM | 9/3/2020 10:27 AM |
| Contacts | Authorizing Official | Update | Change Request | ARMSTRONG, ROGER
CFO
Pioneers Memorial Healthcare District
7603513590 | Loper, Carly
Interim CFO
Pioneers Memorial Healthcare
7603513954 | 5/15/2020 6:55 AM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 12:56:03 PM | 8/21/2019 7:23:26 PM | 8/21/2019 7:23 PM |
| Details | Last Recertification Date | Update | Recertification | 11/17/2017 5:46:13 PM | 8/22/2018 12:56:03 PM | 8/22/2018 12:56 PM |
| Details | Entity Name | Update | Recertification | PIONEERS MEM. HOSPITAL | PIONEERS MEMORIAL HOSPITAL | 11/18/2017 12:17 PM |
| Details | Last Recertification Date | Update | Recertification | | 11/17/2017 5:46:13 PM | 11/17/2017 5:46 PM |
| Contacts | Authorizing Official | Update | | ARMSTRONG, ROGER
CFO
7603513590 | ARMSTRONG, ROGER
CFO
Pioneers Memorial Healthcare District
7603513590 | 10/3/2017 5:16 PM |
| Contacts | Primary Contact | Update | | TEAGUE, JOHN P.
DIRECTOR OF PHARMACY
7603513367 | TEAGUE, JOHN P.
DIRECTOR OF PHARMACY
Pioneers Memorial Healthcare District
7603513367 | 9/19/2017 12:10 PM |
| Contacts | Authorizing Official | Insert | | | ARMSTRONG, ROGER
CFO
7603513590 | 7/26/2017 1:10 PM |
| Contacts | Primary Contact | Insert | | | TEAGUE, JOHN P.
DIRECTOR OF PHARMACY
7603513367 | 7/25/2017 11:06 AM |
| Contacts | Signed By | Insert | | | Campbell, Stephen
COO
7603513550 | 4/3/2017 7:09 AM |
| Addresses | Main Address | Insert | | |
751 W Legion Road Sute 303
Brawley, CA 92227 | 4/3/2017 7:09 AM |
| Addresses | Billing Address | Insert | | | Pioneers Memorial Healthcare District
207 W Legion Road
Brawley, CA 92227 | 4/3/2017 7:09 AM |
| Addresses | Shipping Address | Insert | | | Pioneers Memorial Healthcare District
207 W Legion Road
Brawley, CA 92227 | 4/3/2017 7:09 AM |
| Dates | Participating Approval Date | Update | | | 10/26/2016 12:00:00 AM | 10/26/2016 6:07 PM |
| Details | State | Update | | Pending | Active | 10/26/2016 6:07 PM |
| Dates | Start Date | Update | | | 1/1/2017 12:00:00 AM | 10/26/2016 6:07 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_72699 | DSH050342E | 10/11/2016 11:55 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_72699 | 10/7/2016 4:04 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/7/2016 4:04 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | ZZT40342F | 10/7/2016 4:04 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 10/7/2016 4:04 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1073519443 | 10/7/2016 4:04 PM |
| Details | Last Recertification Date | Insert | | | | 10/7/2016 4:04 PM |
| Details | Grant Number | Insert | | | | 10/7/2016 4:04 PM |
| Details | 340B ID | Insert | | | | 10/7/2016 4:04 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/7/2016 4:04 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/7/2016 4:04 PM |
| Details | Medicare Provider Number | Insert | | | 050342 | 10/7/2016 4:04 PM |
| Details | Entity Name | Insert | | | PIONEERS MEM. HOSPITAL | 10/7/2016 4:04 PM |
| Details | Program Code | Insert | | | DSH | 10/7/2016 4:04 PM |
| Details | Entity Subname | Insert | | | Center for Digestive and Liver Disease-Gastro Srvcs | 10/7/2016 4:04 PM |
| Dates | Participating Approval Date | Insert | | | | 10/7/2016 4:04 PM |
| Details | State | Insert | | | Pending | 10/7/2016 4:04 PM |
| Dates | Registration Date | Insert | | | 10/7/2016 12:00:00 AM | 10/7/2016 4:04 PM |
| Dates | Signed By Date | Insert | | | 10/7/2016 12:00:00 AM | 10/7/2016 4:04 PM |
| Dates | Start Date | Insert | | | | 10/7/2016 4:04 PM |
| Terminations | Termination Comments | Insert | | | | 10/7/2016 4:04 PM |
| Terminations | Termination Date | Insert | | | | 10/7/2016 4:04 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/7/2016 4:04 PM |
| Terminations | Termination Reason | Insert | | | | 10/7/2016 4:04 PM |