Covered Entity Details

DSH050492E Fresno Community Hospital & Medical Center dba Clovis Community Medical Center (Active) - information as of 4/28/2025 1:50:40 AM

Main Details

Name

Fresno Community Hospital & Medical Center dba Clovis Community Medical Center

Subdivision Name

Community Cancer Institute - Infusion Services

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050492E

Medicare Provider Number

050492

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/1/2019

Participating Start Date

7/1/2019

Participating Approval Date

4/2/2019

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Community Medical Center
Tracy Kiritani, VP Hospital Financial Operations
(559) 324-4844

Primary Contact

Community Medical Center
Marcela Magallon, 340B Manager
(559) 244-1387

Addresses

Street Address

785 N. Medical Center DR. West
305
Clovis, CA 93611

Billing Address

Community Regional Medical Center
P.O. Box 1232
Fresno, CA 93715-1231

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	HSP04092F	1316027709

Shipping Addresses

Shipping Address 1

Community Cancer Center Infusion Pharmacy
785 N. Medical Center DR. West
304
Clovis, CA 93611

Shipping Address 2

Community Ambulatory Infusion Center
729 N Medical Center Dr W
213
Clovis, CA 93611-6879

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
DSH050492A	Child	DSH	Fresno Community Hospital & Medical Center dba Clovis Community Medical Center	Community Physical Therapy	729 Medical Center Drive West Ste 121	Clovis	CA	Terminated
DSH050492D	Child	DSH	Fresno Community Hospital & Medical Center dba Clovis Community Medical Center	Wound Care Clinic	688 Medical Center Drive East	Clovis	CA	Active
DSH050492E	Child	DSH	Fresno Community Hospital & Medical Center dba Clovis Community Medical Center	Community Cancer Institute - Infusion Services	785 N. Medical Center DR. West	Clovis	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Kiritani, Tracy CFO Community Medical Center 5593244844	Kiritani, Tracy VP Hospital Financial Operations Community Medical Center 5593244844	2/19/2025 7:25 AM
Contacts	Signed By	Update	Profile Change Request	Kiritani, Tracy CFO Community Medical Center 5593244844	Kiritani, Tracy VP Hospital Financial Operations Community Medical Center 5593244844	2/19/2025 7:25 AM
Contacts	Primary Contact	Update	Profile Change Request	Magallon, Marcela 340B Manaer Community Medical Center 5592441387	Magallon, Marcela 340B Manager Community Medical Center 5592441387	2/18/2025 7:06 PM
Details	Last Recertification Date	Update	Recertification	8/25/2023 1:20:54 PM	8/15/2024 5:07:40 PM	8/15/2024 5:07 PM
Addresses	Shipping Address	Insert	Change Request		Community Ambulatory Infusion Center 729 N Medical Center Dr W 213 Clovis, CA 93611-6879	9/13/2023 7:31 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 1:01:10 PM	8/25/2023 1:20:54 PM	8/25/2023 1:20 PM
Contacts	Primary Contact	Update	Change Request	Weber, Joel 340B Program Director Community Medical Center 5592311504	Magallon, Marcela 340B Manaer Community Medical Center 5592441387	6/14/2023 7:14 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 5:09:23 PM	8/26/2022 1:01:10 PM	8/26/2022 1:01 PM
Details	Last Recertification Date	Update	Recertification	8/21/2020 4:22:26 PM	8/24/2021 5:09:23 PM	8/24/2021 5:09 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	HSP40492F (CA)		8/21/2020 4:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/21/2020 4:22 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		HSP04092F	8/21/2020 4:22 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/21/2020 4:22 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1316027709 ( )		8/21/2020 4:22 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1316027709	8/21/2020 4:22 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/21/2020 4:22 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 6:12:20 PM	8/21/2020 4:22:26 PM	8/21/2020 4:22 PM
Details	Last Recertification Date	Update	Recertification		8/27/2019 6:12:20 PM	8/27/2019 6:12 PM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Kiritani, Tracy CFO Community Medical Center 5593244844	4/2/2019 8:27 AM
Details	340B ID	Update	New Registration		DSH050492E	4/2/2019 8:27 AM
Details	Entity Name	Update	New Registration	CLOVIS COMMUNITY MEDICAL CENTER	Fresno Community Hospital & Medical Center dba Clovis Community Medical Center	4/2/2019 8:27 AM
Details	Entity Subname	Update	New Registration	Community Cancer Institute	Community Cancer Institute - Infusion Services	4/2/2019 8:27 AM
Dates	Participating Approval Date	Update	New Registration		4/2/2019 8:27:24 AM	4/2/2019 8:27 AM
Details	State	Update	New Registration	Pending	Approved	4/2/2019 8:27 AM
Dates	Signed By Date	Update	New Registration		4/1/2019 9:09:59 PM	4/2/2019 8:27 AM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	4/2/2019 8:27 AM
Addresses	Main Address	Insert	New Registration		785 N. Medical Center DR. West 305 Clovis, CA 93611	4/1/2019 4:08 PM
Addresses	Billing Address	Insert	New Registration		Community Regional Medical Center P.O. Box 1232 Fresno, CA 93715-1231	4/1/2019 4:08 PM
Addresses	Shipping Address	Insert	New Registration		Community Cancer Center Infusion Pharmacy 785 N. Medical Center DR. West 304 Clovis, CA 93611	4/1/2019 4:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2019 4:08 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HSP40492F	4/1/2019 4:08 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/1/2019 4:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316027709	4/1/2019 4:08 PM
Contacts	Primary Contact	Insert	New Registration		Weber, Joel 340B Program Director Community Medical Center 5592311504	4/1/2019 4:08 PM
Contacts	Authorizing Official	Insert	New Registration		Kiritani, Tracy CFO Community Medical Center 5593244844	4/1/2019 4:08 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2019 4:08 PM
Details	Grant Number	Insert	New Registration			4/1/2019 4:08 PM
Details	340B ID	Insert	New Registration			4/1/2019 4:08 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2019 4:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2019 4:08 PM
Details	Medicare Provider Number	Insert	New Registration		050492	4/1/2019 4:08 PM
Details	Entity Name	Insert	New Registration		CLOVIS COMMUNITY MEDICAL CENTER	4/1/2019 4:08 PM
Details	Program Code	Insert	New Registration		DSH	4/1/2019 4:08 PM
Details	Entity Subname	Insert	New Registration		Community Cancer Institute	4/1/2019 4:08 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2019 4:08 PM
Details	State	Insert	New Registration		Pending	4/1/2019 4:08 PM
Dates	Registration Date	Insert	New Registration		4/1/2019 4:08:46 PM	4/1/2019 4:08 PM
Dates	Signed By Date	Insert	New Registration			4/1/2019 4:08 PM
Dates	Start Date	Insert	New Registration			4/1/2019 4:08 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2019 4:08 PM
Terminations	Termination Date	Insert	New Registration			4/1/2019 4:08 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2019 4:08 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2019 4:08 PM