Covered Entity Details

PED053305-19 LUCILE PACKARD CHILDRENS HOSPITAL (Terminated) - information as of 4/25/2025 5:41:17 PM

Main Details

Name

LUCILE PACKARD CHILDRENS HOSPITAL

Subdivision Name

Sunnyvale - Health Specialty Services

Type

Children's Hospital

Rural

340B ID

PED053305-19

Medicare Provider Number

053305

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/11/2017

Participating Start Date

4/1/2017

Participating Approval Date

1/17/2017

Last Recertification Date

Termination Date
Termination Reason

4/1/2017
Site closure

Contacts

Authorizing Official

Lucile Packard Children's Hospital
Rick Stephen Majzun, COO
(650) 723-0418

Primary Contact

Lucile Packard Children's Hospital
Mindy Chuang, Pharmacy Finance Manager
(650) 736-4075

Addresses

Street Address

1195 West Fremont Avenue
Sunnyvale, CA 94087

Billing Address

LUCILE PACKARD CHILDREN'S HOSPITAL-ACCOUNTS PAYABLE
725 WELCH ROAD MC5553
PALO ALTO, CA 94304

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	HSC,ZZR11103G
		1467442749,1447313770

Shipping Addresses

Shipping Address 1

LUCILE PACKARD CHILDREN'S HOSPITAL-PHARMACY DEPARTMENT
725 WELCH ROAD
PALO ALTO, CA 94304

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED053305-01	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	MED SPECIALITIES	730 WELCH ROAD	PALO ALTO	CA	Active
PED053305-02	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	SOUTH BAY/LOS GATOS	14601 South Bascom Ave	LOS GATOS	CA	Terminated
PED053305-03	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	CASTRO COMMONS	1174 CASTRO ST.	MOUNTAIN VIEW	CA	Terminated
PED053305-04	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	NEUROSCIENCES	730 WELCH ROAD	PALO ALTO	CA	Active
PED053305-05	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	PRIMARY CARE	730 WELCH ROAD	PALO ALTO	CA	Active
PED053305-06	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	RENAL	770 WELCH ROAD	PALO ALTO	CA	Active
PED053305-07	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	RESP. SPECIALTIES	730 WELCH ROAD	PALO ALTO	CA	Active
PED053305-08	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	SURG SPECIALITIES	730 WELCH ROAD	PALO ALTO	CA	Active
PED053305-09	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	MOBILE HEALTH - VAN	725 WELCH ROAD	PALO ALTO	CA	Active
PED053305-10	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	CARDIOLOGY	725 WELCH ROAD	PALO ALTO	CA	Terminated
PED053305-11	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	OB	770 WELCH ROAD	PALO ALTO	CA	Active
PED053305-12	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	HEMATOLOGY	725 WELCH ROAD	PALO ALTO	CA	Terminated
PED053305-13	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	INFANT DEVELOPMENT	730 WELCH ROAD	PALO ALTO	CA	Active
PED053305-14	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	ONC/STEM CELL	725 WELCH ROAD	PALO ALTO	CA	Terminated
PED053305-15	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	CHILD PSYCH	401 QUARRY ROAD	PALO ALTO	CA	Terminated
PED053305-16	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	DERMATOLOGY	770 WELCH ROAD	PALO ALTO	CA	Terminated
PED053305-17	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	PULMONARY	770 WELCH ROAD	PALO ALTO	CA	Active
PED053305-18	Child	PED	LUCILE PACKARD CHILDRENS HOSPITAL	Fertility Services	1195 West Fremont Avenue	Sunnyvale	CA	Terminated
PED053305-19	Child	PED	LUCILE PACKARD CHILDRENS HOSPITAL	Sunnyvale - Health Specialty Services	1195 West Fremont Avenue	Sunnyvale	CA	Terminated
PED053305-20	Child	PED	LUCILE PACKARD CHILDREN'S HOSPITAL	RADIOLOGY-MRI	732 WELCH ROAD	PALO ALTO	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	CHUANG, MINDY Manager, 340B Program and Contract Pharmacies Lucile Packard Children's Hospital 6507364075	Chuang, Mindy Pharmacy Finance Manager Lucile Packard Children's Hospital 6507364075	9/21/2021 6:34 AM
Medicaid Billing	Medicaid: Number	Update		HSC	HSC	12/10/2020 4:18 PM
Medicaid Billing	Medicaid: Number	Update		ZZR11103G	ZZR11103G	12/10/2020 4:18 PM
Contacts	Authorizing Official	Update	AO Change Request	Haering, Dana Chief Financial Officer Lucile Packard Children's Hospital Stanford 6507212222	Majzun, Rick Stephen COO Lucile Packard Children's Hospital 6507230418	11/12/2019 9:18 AM
Contacts	Primary Contact	Update	Profile Change Request	CHUANG, MINDY PHARMACY COMPLIANCE ANALYST Lucile Packard Children's Hospital 6507364075	CHUANG, MINDY Manager, 340B Program and Contract Pharmacies Lucile Packard Children's Hospital 6507364075	8/20/2019 6:01 PM
Contacts	Authorizing Official	Update		Haering, Dana Chief Financial Officer 6507212222	Haering, Dana Chief Financial Officer Lucile Packard Children's Hospital Stanford 6507212222	10/19/2017 2:48 PM
Contacts	Primary Contact	Update		CHUANG, MINDY PHARMACY COMPLIANCE ANALYST 6507364075	CHUANG, MINDY PHARMACY COMPLIANCE ANALYST Lucile Packard Children's Hospital 6507364075	9/28/2017 2:19 PM
Contacts	Authorizing Official	Insert			Haering, Dana Chief Financial Officer 6507212222	5/1/2017 12:55 PM
Contacts	Signed By	Insert			McCune, Anne COO 6504978325	3/15/2017 6:29 PM
Contacts	Primary Contact	Insert			CHUANG, MINDY PHARMACY COMPLIANCE ANALYST 6507364075	3/15/2017 6:29 PM
Addresses	Main Address	Insert			1195 West Fremont Avenue Sunnyvale, CA 94087	3/15/2017 6:29 PM
Addresses	Billing Address	Insert			LUCILE PACKARD CHILDREN'S HOSPITAL-ACCOUNTS PAYABLE 725 WELCH ROAD MC5553 PALO ALTO, CA 94304	3/15/2017 6:29 PM
Addresses	Shipping Address	Insert			LUCILE PACKARD CHILDREN'S HOSPITAL-PHARMACY DEPARTMENT 725 WELCH ROAD PALO ALTO, CA 94304	3/15/2017 6:29 PM
Dates	Last Date That 340B Drugs Purchased	Update			3/15/2017 12:00:00 AM	3/15/2017 6:28 PM
Details	State	Update		Active	Terminated	3/15/2017 6:28 PM
Terminations	Termination Comments	Update			This site was registered on 1/11/2017 with Start Date 4/1/2017. The covered entity has determined that we will not be using 340B drugs for this site. The termination request has been submitted PRIOR to the Start Date 4/1/2017. 340B drugs were never purchased for this site.	3/15/2017 6:28 PM
Terminations	Termination Date	Update			4/1/2017 12:00:00 AM	3/15/2017 6:28 PM
Terminations	Termination Effective Date	Update			3/15/2017 12:00:00 AM	3/15/2017 6:28 PM
Terminations	Termination Reason	Update			Site closure	3/15/2017 6:28 PM
Dates	Participating Approval Date	Update			1/17/2017 12:00:00 AM	1/17/2017 4:30 PM
Details	State	Update		Pending	Active	1/17/2017 4:30 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	1/17/2017 4:30 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_74589	PED053305-19	1/17/2017 7:17 AM
Details	Entity Subname	Update		Sunnyvale	Sunnyvale - Health Specialty Services	1/17/2017 7:17 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_74589	1/11/2017 6:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/11/2017 6:24 PM
Medicaid Billing	Medicaid: Number	Insert			HSC	1/11/2017 6:24 PM
Medicaid Billing	Medicaid: State	Insert			CA	1/11/2017 6:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/11/2017 6:24 PM
Medicaid Billing	Medicaid: Number	Insert			ZZR11103G	1/11/2017 6:24 PM
Medicaid Billing	Medicaid: State	Insert			CA	1/11/2017 6:24 PM
Medicaid Billing	NPI: Number	Insert			1467442749	1/11/2017 6:24 PM
Medicaid Billing	NPI: Number	Insert			1447313770	1/11/2017 6:24 PM
Details	Last Recertification Date	Insert				1/11/2017 6:24 PM
Details	Grant Number	Insert				1/11/2017 6:24 PM
Details	340B ID	Insert				1/11/2017 6:24 PM
Details	Is Authorizing Official EHB Data	Insert				1/11/2017 6:24 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/11/2017 6:24 PM
Details	Medicare Provider Number	Insert			053305	1/11/2017 6:24 PM
Details	Entity Name	Insert			LUCILE PACKARD CHILDRENS HOSPITAL	1/11/2017 6:24 PM
Details	Program Code	Insert			PED	1/11/2017 6:24 PM
Details	Entity Subname	Insert			Sunnyvale	1/11/2017 6:24 PM
Dates	Participating Approval Date	Insert				1/11/2017 6:24 PM
Details	State	Insert			Pending	1/11/2017 6:24 PM
Dates	Registration Date	Insert			1/11/2017 12:00:00 AM	1/11/2017 6:24 PM
Dates	Signed By Date	Insert			1/11/2017 12:00:00 AM	1/11/2017 6:24 PM
Dates	Start Date	Insert				1/11/2017 6:24 PM
Terminations	Termination Comments	Insert				1/11/2017 6:24 PM
Terminations	Termination Date	Insert				1/11/2017 6:24 PM
Terminations	Termination Effective Date	Insert				1/11/2017 6:24 PM
Terminations	Termination Reason	Insert				1/11/2017 6:24 PM