| Contacts | Primary Contact | Update | Group Change Request | Dennen, Minh-Thu
Director of Pharmacy
Washington Hospital
5108186114 | Dennen, Minh-Thu
Director of Pharmacy
Washington Hospital Healthcare System
5108186114 | 4/25/2025 6:42 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | LaBossiere, Larry
VP & COO
Washington Hospital Healthcare System
5108186586 | LaBossiere, Larry
SVP & COO
Washington Hospital Healthcare System
5108186586 | 4/16/2025 6:40 AM |
| Addresses | Shipping Address | Insert | Change Request | | Washington Hospital HealthCare System
2000 MOWRY AVE
FREMONT, CA 94538 | 4/16/2025 6:16 AM |
| Contacts | Authorizing Official | Update | AO Change Request | McDonagh, Thomas M
VP & CFO
Washington Hospital Healthcare System
5108186770 | LaBossiere, Larry
VP & COO
Washington Hospital Healthcare System
5108186586 | 4/3/2025 3:09 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | McDonagh, Thomas
VP & CFO
Washington Hospital Healthcare System
5108186770 | McDonagh, Thomas M
VP & CFO
Washington Hospital Healthcare System
5108186770 | 8/23/2024 5:58 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2023 2:34:04 PM | 8/23/2024 5:57:42 PM | 8/23/2024 5:57 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Fayen, Edward
Exec VP & Chief of Operations
Washington Hospital Healthcare System
5108186513 | McDonagh, Thomas
VP & CFO
Washington Hospital Healthcare System
5108186770 | 8/23/2023 3:10 PM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2022 1:48:05 PM | 8/23/2023 2:34:04 PM | 8/23/2023 2:34 PM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2021 12:47:54 PM | 9/9/2022 1:48:05 PM | 9/9/2022 1:48 PM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2020 6:44:03 PM | 8/20/2021 12:47:54 PM | 8/20/2021 12:47 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 8/25/2020 6:44 PM |
| Contacts | Primary Contact | Update | Recertification | DENNEN, MINH-THU
DIRECTOR OF PHARMACY
Washington Hospital Healthcare System
5106086114 | Dennen, Minh-Thu
Director of Pharmacy
Washington Hospital
5108186114 | 8/25/2020 6:44 PM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2019 12:57:36 PM | 8/25/2020 6:44:03 PM | 8/25/2020 6:44 PM |
| Details | Entity Name | Update | Recertification | WASHINGTON HOSPITAL DISTRICT | WASHINGTON HOSPITAL HEALTHCARE SYSTEM | 9/19/2019 8:13 AM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 8:44:39 PM | 8/22/2019 12:57:36 PM | 8/22/2019 12:57 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Fayen, Edward
Sr Associate Administrator, Operations & Support
Washington Hospital Healthcare System
5107456579 | Fayen, Edward
Exec VP & Chief of Operations
Washington Hospital Healthcare System
5108186513 | 8/22/2019 12:50 PM |
| Details | Last Recertification Date | Update | Recertification | 12/6/2017 2:47:41 PM | 8/22/2018 8:44:39 PM | 8/22/2018 8:44 PM |
| Addresses | Billing Address | Insert | Change Request | | Washington Hospital Healthcare System
2000 Mowry Ave
Fremont, CA 94538 | 4/17/2018 7:11 AM |
| Addresses | Main Address | Update | Change Request |
2000 Mowry Ave
Fremont, CA 94538-1716 |
2500 Mowry Ave
Fremont, CA 94538-1716 | 4/17/2018 7:11 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Henry, Christopher
Chief Financial Officer
Washington Hospital Healthcare System
5107456592 | Fayen, Edward
Sr Associate Administrator, Operations & Support
Washington Hospital Healthcare System
5107456579 | 12/6/2017 3:05 PM |
| Contacts | Primary Contact | Update | Recertification | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
Washington Hospital Healthcare System
5107456592 | DENNEN, MINH-THU
DIRECTOR OF PHARMACY
Washington Hospital Healthcare System
5106086114 | 12/6/2017 2:47 PM |
| Details | Last Recertification Date | Update | Recertification | | 12/6/2017 2:47:41 PM | 12/6/2017 2:47 PM |
| Contacts | Primary Contact | Update | | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
5107456592 | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
Washington Hospital Healthcare System
5107456592 | 12/6/2017 2:14 PM |
| Contacts | Signed By | Update | | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
5107456592 | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
Washington Hospital Healthcare System
5107456592 | 12/6/2017 2:14 PM |
| Contacts | Authorizing Official | Update | AO Change Request | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
5107456592 | Henry, Christopher
Chief Financial Officer
Washington Hospital Healthcare System
5107456592 | 12/6/2017 2:12 PM |
| Addresses | Main Address | Insert | | |
2000 Mowry Ave
Fremont, CA 94538-1716 | 7/25/2017 6:00 PM |
| Contacts | Authorizing Official | Insert | | | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
5107456592 | 7/25/2017 6:00 PM |
| Contacts | Primary Contact | Insert | | | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
5107456592 | 7/25/2017 6:00 PM |
| Contacts | Signed By | Insert | | | HENRY, CHRISTOPHER
CHIEF FINANCIAL OFFICER
5107456592 | 7/25/2017 6:00 PM |
| Details | State | Update | | Approved | Active | 7/25/2017 6:00 PM |
| Dates | Participating Approval Date | Update | | | 7/25/2017 12:00:00 AM | 7/25/2017 6:00 PM |
| Details | State | Update | | Pending | Approved | 7/25/2017 6:00 PM |
| Dates | Start Date | Update | | | 10/1/2017 12:00:00 AM | 7/25/2017 6:00 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_78818 | DSH050195A | 7/22/2017 12:21 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_78818 | 7/14/2017 5:41 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 7/14/2017 5:41 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 050195 | 7/14/2017 5:41 PM |
| Medicaid Billing | Medicaid: State | Insert | | | CA | 7/14/2017 5:41 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1780614685 | 7/14/2017 5:41 PM |
| Details | Last Recertification Date | Insert | | | | 7/14/2017 5:41 PM |
| Details | Grant Number | Insert | | | | 7/14/2017 5:41 PM |
| Details | 340B ID | Insert | | | | 7/14/2017 5:41 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/14/2017 5:41 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/14/2017 5:41 PM |
| Details | Medicare Provider Number | Insert | | | 050195 | 7/14/2017 5:41 PM |
| Details | Entity Name | Insert | | | WASHINGTON HOSPITAL DISTRICT | 7/14/2017 5:41 PM |
| Details | Program Code | Insert | | | DSH | 7/14/2017 5:41 PM |
| Details | Entity Subname | Insert | | | Infusion Center | 7/14/2017 5:41 PM |
| Dates | Participating Approval Date | Insert | | | | 7/14/2017 5:41 PM |
| Details | State | Insert | | | Pending | 7/14/2017 5:41 PM |
| Dates | Registration Date | Insert | | | 7/14/2017 12:00:00 AM | 7/14/2017 5:41 PM |
| Dates | Signed By Date | Insert | | | 7/14/2017 12:00:00 AM | 7/14/2017 5:41 PM |
| Dates | Start Date | Insert | | | | 7/14/2017 5:41 PM |
| Terminations | Termination Comments | Insert | | | | 7/14/2017 5:41 PM |
| Terminations | Termination Date | Insert | | | | 7/14/2017 5:41 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/14/2017 5:41 PM |
| Terminations | Termination Reason | Insert | | | | 7/14/2017 5:41 PM |