Covered Entity Details

DSH050382J EMANATE HEALTH MEDICAL CENTER (Active) - information as of 6/9/2025 11:05:03 PM

Main Details

Name

EMANATE HEALTH MEDICAL CENTER

Subdivision Name

QVH - MRI - MRI

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050382J

Medicare Provider Number

050382

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2019

Participating Start Date

4/1/2019

Participating Approval Date

1/16/2019

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Emanate Health
Gurjeet Kalkat, Chief Medical Officier
(626) 337-7331

Primary Contact

Emanate Health Medical Center-Inter-Community & Queen of the Valley Hospitals
Lori Jackson, Pharmacy 340B Program Coordinator
(626) 813-2953

Addresses

Street Address

1115 S Sunset Ave.
West Covina, CA 91790

Billing Address

Emanate Health Medical Center – Queen of the Valley Hospital
PO Box 6108
Covina, CA 91722-5108

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	HSC30369F	1063441293,1174301022

Shipping Addresses

Shipping Address 1

Emanate Health Medical Center Pharmacy
1135 S. Sunset Ave., Suite #104
West Covina, CA 91791-3965

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
DSH050382A	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - SPEECH THERAPY - SPEECH THERAPY	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382AA	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH HEMATOLOGY/ONC 1206D - QVH HEMATOLOGY/ONC 1206D	1115 S SUNSET AVE.	WEST COVINA	CA	Active
DSH050382B	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - ANESTHESIOLOGY - ANESTHESIOLOGY	1115 S Sunset Ave,	West Covina	CA	Active
DSH050382C	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - CARDIOLOGY - EKG - CARDIOLOGY - EKG	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382D	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - ANGIO SUITE - INTERVENTIONAL RADIOLOGY - ANGIO SUITE - INTERVENTIONAL RADIOLOGY	1115 S Sunset Ave,	West Covina	CA	Active
DSH050382E	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - CT SCANNER - CT SCANNER	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382F	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - EMERGENCY SERVICES - EMERGENCY SERVICES	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382G	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - G.I. LAB - G.I. LAB	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382H	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - LAB - CLINICAL - LAB - CLINICAL	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382J	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - MRI - MRI	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382K	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - NEUROLOGY - EEG - NEUROLOGY - EEG	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382L	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - NUCLEAR MEDICINE - NUCLEAR MEDICINE	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382M	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - OB EVALUATION - OB EVALUATION	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382N	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - OCCUPATIONAL THERAPY - OCCUPATIONAL THERAPY	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382P	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - PATIENT COUNSELING-DIABETES CENTER - PATIENT COUNSELING-DIABETES CENTER	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382Q	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - PHYSICAL THERAPY - PHYSICAL THERAPY	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382R	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - RADIOLOGY DIAGNOSTIC - RADIOLOGY DIAGNOSTIC	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382S	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - RECOVERY ROOM - RECOVERY ROOM	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382T	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - RENAL DIALYSIS - RENAL DIALYSIS	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382U	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - RESPIRATORY THERAPY - NICU - RESPIRATORY THERAPY - NICU	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382V	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - RESPIRATORY THERAPY - RESPIRATORY THERAPY	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382W	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - SURGERY - GENERAL - SURGERY - GENERAL	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382X	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - ULTRASOUND - ULTRASOUND	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382Y	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH - CANCER TREATMENT ROOM -MEDICAL ONCOLOGY - CANCER TREATMENT ROOM -MEDICAL ONCOLOGY	1115 S Sunset Ave.	West Covina	CA	Active
DSH050382Z	Child	DSH	EMANATE HEALTH MEDICAL CENTER	QVH INFUSION TREATMENT - QVH INFUSION TREATMENT	1115 S SUNSET AVE.	WEST COVINA	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Group Change Request		1174301022	3/4/2025 2:34 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	3/4/2025 2:34 PM
Addresses	Shipping Address	Insert	Group Change Request		Emanate Health Medical Center Pharmacy 1135 S. Sunset Ave., Suite #104 West Covina, CA 91791-3965	8/28/2024 10:47 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 1:58:15 PM	8/21/2024 3:28:09 PM	8/21/2024 3:28 PM
Addresses	Shipping Address	Delete	Group Change Request	Emanate Health Medical Center Pharmacy 1135 S. Sunset Ave., Suite #104 West Covina, CA 91791-3965		5/14/2024 6:32 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 4:35:01 PM	8/15/2023 1:58:15 PM	8/15/2023 1:58 PM
Addresses	Shipping Address	Insert	Group Change Request		Emanate Health Medical Center Pharmacy 1135 S. Sunset Ave., Suite #104 West Covina, CA 91791-3965	8/7/2023 6:47 AM
Details	Last Recertification Date	Update	Recertification	8/19/2021 1:54:45 PM	9/1/2022 4:35:01 PM	9/1/2022 4:35 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 5:59:56 PM	8/19/2021 1:54:45 PM	8/19/2021 1:54 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/10/2020 5:59 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 1:28:07 PM	9/10/2020 5:59:56 PM	9/10/2020 5:59 PM
Contacts	Authorizing Official	Update	Change Request	Kalkat, Gurjeet Chief Medical Officer Citrus Valley Health Partners 6263317331	Kalkat, Gurjeet Chief Medical Officier Emanate Health 6263377331	3/13/2020 9:12 AM
Contacts	Primary Contact	Update	Change Request	Jackson, Lori Pharmacy 340B Program Coordinator Emanate Health Medical Center-Inter-Community & Queen of the Valley Hospitals 6268132953	Jackson, Lori Pharmacy 340B Program Coordinator Emanate Health Medical Center-Inter-Community & Queen of the Valley Hospitals 6268132953	3/2/2020 8:13 AM
Addresses	Billing Address	Update	Change Request	Emanate Health Medical Center - Queen of the Valley Hospital PO Box 6108 Covina, CA 91722-5108	Emanate Health Medical Center – Queen of the Valley Hospital PO Box 6108 Covina, CA 91722-5108	8/25/2019 9:27 PM
Addresses	Billing Address	Insert	Recertification		Emanate Health Medical Center - Queen of the Valley Hospital PO Box 6108 Covina, CA 91722-5108	8/22/2019 1:28 PM
Details	Last Recertification Date	Update	Recertification		8/22/2019 1:28:07 PM	8/22/2019 1:28 PM
Details	Entity Name	Update	Change Request	CITRUS VALLEY MEDICAL CENTER	EMANATE HEALTH MEDICAL CENTER	4/11/2019 2:00 PM
Contacts	Primary Contact	Update	Profile Change Request	Jackson, Lori Pharmacy 340B Program Coordinator Emanate Health Medical Center-InterCommunity Hospital 6268132953	Jackson, Lori Pharmacy 340B Program Coordinator Emanate Health Medical Center-Inter-Community & Queen of the Valley Hospitals 6268132953	4/4/2019 1:49 PM
Contacts	Primary Contact	Update	Profile Change Request	Jackson, Lori Pharmacy 340B Program Coordinator Citrus Valley Medical Center-InterCommunity Hospital 6268132953	Jackson, Lori Pharmacy 340B Program Coordinator Emanate Health Medical Center-InterCommunity Hospital 6268132953	4/4/2019 1:43 PM
Details	State	Update		Approved	Active	4/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Kalkat, Gurjeet Chief Medical Officer Citrus Valley Health Partners 6263317331	1/16/2019 1:42 PM
Details	340B ID	Update	New Registration		DSH050382J	1/16/2019 1:42 PM
Details	Entity Subname	Update	New Registration	QVH - MRI	QVH - MRI - MRI	1/16/2019 1:42 PM
Dates	Participating Approval Date	Update	New Registration		1/16/2019 1:42:30 PM	1/16/2019 1:42 PM
Details	State	Update	New Registration	Pending	Approved	1/16/2019 1:42 PM
Dates	Signed By Date	Update	New Registration		1/15/2019 8:27:18 PM	1/16/2019 1:42 PM
Dates	Start Date	Update	New Registration		4/1/2019 12:00:00 AM	1/16/2019 1:42 PM
Addresses	Main Address	Insert	New Registration		1115 S Sunset Ave. West Covina, CA 91790	1/15/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HSC30369F	1/15/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	1/15/2019 4:51 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063441293	1/15/2019 4:51 PM
Contacts	Authorizing Official	Insert	New Registration		Kalkat, Gurjeet Chief Medical Officer Citrus Valley Health Partners 6263317331	1/15/2019 4:51 PM
Contacts	Primary Contact	Insert	New Registration		Jackson, Lori Pharmacy 340B Program Coordinator Citrus Valley Medical Center-InterCommunity Hospital 6268132953	1/15/2019 4:51 PM
Details	Last Recertification Date	Insert	New Registration			1/15/2019 4:51 PM
Details	Grant Number	Insert	New Registration			1/15/2019 4:51 PM
Details	340B ID	Insert	New Registration			1/15/2019 4:51 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2019 4:51 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2019 4:51 PM
Details	Medicare Provider Number	Insert	New Registration		050382	1/15/2019 4:51 PM
Details	Entity Name	Insert	New Registration		CITRUS VALLEY MEDICAL CENTER	1/15/2019 4:51 PM
Details	Program Code	Insert	New Registration		DSH	1/15/2019 4:51 PM
Details	Entity Subname	Insert	New Registration		QVH - MRI	1/15/2019 4:51 PM
Dates	Participating Approval Date	Insert	New Registration			1/15/2019 4:51 PM
Details	State	Insert	New Registration		Pending	1/15/2019 4:51 PM
Dates	Registration Date	Insert	New Registration		1/15/2019 4:51:05 PM	1/15/2019 4:51 PM
Dates	Signed By Date	Insert	New Registration			1/15/2019 4:51 PM
Dates	Start Date	Insert	New Registration			1/15/2019 4:51 PM
Terminations	Termination Comments	Insert	New Registration			1/15/2019 4:51 PM
Terminations	Termination Date	Insert	New Registration			1/15/2019 4:51 PM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2019 4:51 PM
Terminations	Termination Reason	Insert	New Registration			1/15/2019 4:51 PM