Covered Entity Details

DSH050099D SAN ANTONIO REGIONAL HOSPITAL (Active) - information as of 4/30/2025 12:01:04 AM

Main Details

Name

SAN ANTONIO REGIONAL HOSPITAL

Subdivision Name

Sierra / Urgent Care - Urgent Care

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050099D

Medicare Provider Number

050099

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/12/2017

Participating Start Date

1/1/2018

Participating Approval Date

11/15/2017

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

San Antonio Regional Hospital
Peter Aprato, Compliance Officer
(909) 694-1098

Primary Contact

San Antonio Regional Hospital
Dennis Ancheta, Director of Pharmacy
(909) 920-4849 Ext: 24849

Addresses

Street Address

16465 Sierra Lakes Pkwy
Fontana, CA 92336

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		1780681189

Shipping Addresses

Shipping Address 1

San Antonio Regional Hospital
999 San Bernardino Road, Building 5, Room 118
Upland, CA 91786

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
DSH050099A	Child	DSH	SAN ANTONIO REGIONAL HOSPITAL	Rancho Cucamonga / Urgent Care	7777-A Milliken Avenue	Rancho Cucamonga	CA	Active
DSH050099B	Child	DSH	SAN ANTONIO REGIONAL HOSPITAL	Fontana / Urgent Care	16465 Sierra Lakes Parkway	Fontana	CA	Terminated
DSH050099C	Child	DSH	SAN ANTONIO REGIONAL HOSPITAL	Eastvale / Urgent Care	12442 Limonite Avenue	Eastvale	CA	Active
DSH050099D	Child	DSH	SAN ANTONIO REGIONAL HOSPITAL	Sierra / Urgent Care - Urgent Care	16465 Sierra Lakes Pkwy	Fontana	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/30/2023 6:29:32 PM	8/20/2024 2:25:28 PM	8/20/2024 2:25 PM
Details	Last Recertification Date	Update	Recertification	9/9/2022 12:37:38 PM	8/30/2023 6:29:32 PM	8/30/2023 6:29 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 12:49:30 PM	9/9/2022 12:37:38 PM	9/9/2022 12:37 PM
Contacts	Primary Contact	Update	Profile Change Request	Ancheta, Dennis Interim Director of Pharmacy San Antonio Regional Hospital 9099204849	Ancheta, Dennis Director of Pharmacy San Antonio Regional Hospital 9099204849-24849	10/18/2021 11:59 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 2:01:43 PM	8/16/2021 12:49:30 PM	8/16/2021 12:49 PM
Addresses	Shipping Address	Update	Change Request	San Antonio Regional Hospital 999 San Bernadino Road Upland, CA 91786	San Antonio Regional Hospital 999 San Bernardino Road, Building 5, Room 118 Upland, CA 91786	8/5/2021 6:56 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 2:01 PM
Details	Last Recertification Date	Update	Recertification	8/19/2019 2:45:58 PM	9/1/2020 2:01:43 PM	9/1/2020 2:01 PM
Contacts	Primary Contact	Update	Change Request	Torres, Martin J Director of Pharmacy San Antonio Regional Hospital 9099204939	Ancheta, Dennis Interim Director of Pharmacy San Antonio Regional Hospital 9099204849	6/15/2020 4:42 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 7:07:25 PM	8/19/2019 2:45:58 PM	8/19/2019 2:45 PM
Contacts	Authorizing Official	Update	Profile Change Request	Aprato, Peter Senior Vice President Administrative Services and Compliance San Antonio Regional Hospital 9099204810	Aprato, Peter Compliance Officer San Antonio Regional Hospital 9096941098	11/27/2018 3:22 PM
Contacts	Signed By	Update	Profile Change Request	Aprato, Peter Senior Vice President Administrative Services and Compliance San Antonio Regional Hospital 9099204810	Aprato, Peter Compliance Officer San Antonio Regional Hospital 9096941098	11/27/2018 3:22 PM
Details	Last Recertification Date	Update	Recertification		8/22/2018 7:07:25 PM	8/22/2018 7:07 PM
Contacts	Primary Contact	Update	Change Request	Vo, Jacqueline Pharmacy Director San Antonio Regional Hospital 9099204939	Torres, Martin J Director of Pharmacy San Antonio Regional Hospital 9099204939	1/30/2018 3:18 PM
Addresses	Billing Address	Update	Change Request	San Antonio Regional Hospital 999 San Bernadino Road Upland, CA 91786	San Antonio Regional Hospital 999 San Bernadino Road Building 5, Room 118 Upland, CA 91786	11/16/2017 4:53 PM
Details	State	Update	Change Request	Approved	Active	11/16/2017 4:53 PM
Contacts	Signed By	Insert	New Registration		Aprato, Peter Senior Vice President Administrative Services and Compliance San Antonio Regional Hospital 9099204810	11/15/2017 1:20 PM
Details	340B ID	Update	New Registration		DSH050099D	11/15/2017 1:20 PM
Details	Entity Subname	Update	New Registration	Sierra / Urgent Care	Sierra / Urgent Care - Urgent Care	11/15/2017 1:20 PM
Dates	Participating Approval Date	Update	New Registration		11/15/2017 1:20:08 PM	11/15/2017 1:20 PM
Details	State	Update	New Registration	Pending	Approved	11/15/2017 1:20 PM
Dates	Signed By Date	Update	New Registration		10/12/2017 5:46:01 PM	11/15/2017 1:20 PM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	11/15/2017 1:20 PM
Addresses	Main Address	Insert	New Registration		16465 Sierra Lakes Pkwy Fontana, CA 92336	10/12/2017 5:45 PM
Addresses	Billing Address	Insert	New Registration		San Antonio Regional Hospital 999 San Bernadino Road Upland, CA 91786	10/12/2017 5:45 PM
Addresses	Shipping Address	Insert	New Registration		San Antonio Regional Hospital 999 San Bernadino Road Upland, CA 91786	10/12/2017 5:45 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1780681189	10/12/2017 5:45 PM
Contacts	Authorizing Official	Insert	New Registration		Aprato, Peter Senior Vice President Administrative Services and Compliance San Antonio Regional Hospital 9099204810	10/12/2017 5:45 PM
Contacts	Primary Contact	Insert	New Registration		Vo, Jacqueline Pharmacy Director San Antonio Regional Hospital 9099204939	10/12/2017 5:45 PM
Details	Last Recertification Date	Insert	New Registration			10/12/2017 5:45 PM
Details	Grant Number	Insert	New Registration			10/12/2017 5:45 PM
Details	340B ID	Insert	New Registration			10/12/2017 5:45 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/12/2017 5:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/12/2017 5:45 PM
Details	Medicare Provider Number	Insert	New Registration		050099	10/12/2017 5:45 PM
Details	Entity Name	Insert	New Registration		SAN ANTONIO REGIONAL HOSPITAL	10/12/2017 5:45 PM
Details	Program Code	Insert	New Registration		DSH	10/12/2017 5:45 PM
Details	Entity Subname	Insert	New Registration		Sierra / Urgent Care	10/12/2017 5:45 PM
Dates	Participating Approval Date	Insert	New Registration			10/12/2017 5:45 PM
Details	State	Insert	New Registration		Pending	10/12/2017 5:45 PM
Dates	Registration Date	Insert	New Registration		10/12/2017 5:45:58 PM	10/12/2017 5:45 PM
Dates	Signed By Date	Insert	New Registration			10/12/2017 5:45 PM
Dates	Start Date	Insert	New Registration			10/12/2017 5:45 PM
Terminations	Termination Comments	Insert	New Registration			10/12/2017 5:45 PM
Terminations	Termination Date	Insert	New Registration			10/12/2017 5:45 PM
Terminations	Termination Effective Date	Insert	New Registration			10/12/2017 5:45 PM
Terminations	Termination Reason	Insert	New Registration			10/12/2017 5:45 PM