Covered Entity Details

DSH050342H PIONEERS MEMORIAL HOSPITAL (Active) - information as of 5/6/2025 11:12:38 PM

Main Details

Name

PIONEERS MEMORIAL HOSPITAL

Subdivision Name

Pioneers Children's Health Center - Pioneers Children's Health Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050342H

Medicare Provider Number

050342

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2019

Participating Start Date

7/1/2019

Participating Approval Date

5/15/2019

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Pioneers Memorial Hospital
Carly Loper, Chief Financial Officer
(760) 351-3594

Primary Contact

Pioneers Memorial Hospital
John Paul Teague, Director of Pharmacy
(760) 351-3278

Addresses

Street Address

565 Main Street
Brawley, CA 92227

Billing Address

Pioneers Memorial Healthcare District
207 W Legion Rd
Brawley, CA 92227

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	zzt40342f	1760995625,1598560492

Shipping Addresses

Shipping Address 1

Pioneers Memorial Healthcare District
207 W Legion Rd
Brawley, CA 92227

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
DSH050342A	Child	DSH	PIONEERS MEMORIAL HOSPITAL	CALEXICO HEALTH CENTER (RURAL HEALTH CLINIC)	450 EAST BIRCH ST.	CALEXICO	CA	Active
DSH050342B	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Wound Care Center	751 WEST LEGION ROAD SUITE 300	BRAWLEY	CA	Active
DSH050342C	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Oncology Clinic	205 W Legion Road	Brawley	CA	Active
DSH050342D	Child	DSH	PIONEERS MEMORIAL HOSPITAL	PIONEERS HEALTH CENTER (RURAL HEALTH CLINIC)	751 W LEGION ROAD SUITE 103	BRAWLEY	CA	Active
DSH050342E	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Center for Digestive and Liver Disease-Gastro Srvcs	751 W Legion Road Sute 303	Brawley	CA	Active
DSH050342F	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Specialty Center at Pioneers	751 W Legion Road Suite 302	Brawley	CA	Active
DSH050342G	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Surgical Health at Pioneers	751 W Legion Road Suite 305	Brawley	CA	Active
DSH050342H	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Pioneers Children's Health Center - Pioneers Children's Health Center	565 Main Street	Brawley	CA	Active
DSH050342J	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Pioneers Memorial Healthcare District- Comprehensive Women's - Comprehensive Women's Health	751 W Legion Road Suite 204	Brawley	CA	Active
DSH050342K	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Pioneers Memorial Healthcare District-Womens Health - Womens Health at Pioneers	751 W Legion Road Suite 201	Brawley	CA	Active
DSH050342L	Child	DSH	PIONEERS MEMORIAL HOSPITAL	Pioneers Memorial Healthcare District-Urology - Urology	751 W Legion Road Suite 305	Brawley	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Change Request		1598560492	4/2/2025 11:34 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/2/2025 11:34 AM
Contacts	Authorizing Official	Update	Change Request	Loper, Carly Chief Financial Officer Pioneers Memorial Healthcare 7603513594	Loper, Carly Chief Financial Officer Pioneers Memorial Hospital 7603513594	3/17/2025 9:28 AM
Contacts	Primary Contact	Update	Group Change Request	TEAGUE, JOHN P. DIRECTOR OF PHARMACY Pioneers Memorial Healthcare District 7603513367	Teague, John Paul Director of Pharmacy Pioneers Memorial Hospital 7603513278	3/17/2025 7:52 AM
Details	Last Recertification Date	Update	Recertification	9/5/2023 6:41:32 PM	8/19/2024 1:39:53 PM	8/19/2024 1:39 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 11:43:34 AM	9/5/2023 6:41:32 PM	9/5/2023 6:41 PM
Details	Last Recertification Date	Update	Recertification	8/25/2021 2:54:36 PM	9/6/2022 11:43:34 AM	9/6/2022 11:43 AM
Contacts	Authorizing Official	Update	Profile Change Request	Loper, Carly Chief Financial Officer Pioneers Memorial Healthcare 7603513954	Loper, Carly Chief Financial Officer Pioneers Memorial Healthcare 7603513594	8/25/2021 2:57 PM
Details	Last Recertification Date	Update	Recertification	9/3/2020 10:45:54 AM	8/25/2021 2:54:36 PM	8/25/2021 2:54 PM
Contacts	Authorizing Official	Update	Profile Change Request	Loper, Carly Interim CFO Pioneers Memorial Healthcare 7603513954	Loper, Carly Chief Financial Officer Pioneers Memorial Healthcare 7603513954	4/26/2021 7:22 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/3/2020 10:45 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 8:42:53 PM	9/3/2020 10:45:54 AM	9/3/2020 10:45 AM
Contacts	Authorizing Official	Update	Change Request	ARMSTRONG, ROGER CFO Pioneers Memorial Healthcare District 7603513590	Loper, Carly Interim CFO Pioneers Memorial Healthcare 7603513954	5/15/2020 6:55 AM
Addresses	Shipping Address	Insert	Recertification		Pioneers Memorial Healthcare District 207 W Legion Rd Brawley, CA 92227	8/21/2019 8:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/21/2019 8:42 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		zzt40342f	8/21/2019 8:42 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/21/2019 8:42 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760995625	8/21/2019 8:42 PM
Details	Last Recertification Date	Update	Recertification		8/21/2019 8:42:53 PM	8/21/2019 8:42 PM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		ARMSTRONG, ROGER CFO Pioneers Memorial Healthcare District 7603513590	5/15/2019 11:30 AM
Details	340B ID	Update	New Registration		DSH050342H	5/15/2019 11:30 AM
Details	Entity Name	Update	New Registration	PIONEERS MEM. HOSPITAL	PIONEERS MEMORIAL HOSPITAL	5/15/2019 11:30 AM
Details	Entity Subname	Update	New Registration	Pioneers Children's Health Center	Pioneers Children's Health Center - Pioneers Children's Health Center	5/15/2019 11:30 AM
Dates	Participating Approval Date	Update	New Registration		5/15/2019 11:30:13 AM	5/15/2019 11:30 AM
Details	State	Update	New Registration	Pending	Approved	5/15/2019 11:30 AM
Dates	Signed By Date	Update	New Registration		4/15/2019 5:33:27 PM	5/15/2019 11:30 AM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	5/15/2019 11:30 AM
Addresses	Main Address	Insert	New Registration		565 Main Street Brawley, CA 92227	4/15/2019 2:40 PM
Addresses	Billing Address	Insert	New Registration		Pioneers Memorial Healthcare District 207 W Legion Rd Brawley, CA 92227	4/15/2019 2:40 PM
Contacts	Primary Contact	Insert	New Registration		TEAGUE, JOHN P. DIRECTOR OF PHARMACY Pioneers Memorial Healthcare District 7603513367	4/15/2019 2:40 PM
Contacts	Authorizing Official	Insert	New Registration		ARMSTRONG, ROGER CFO Pioneers Memorial Healthcare District 7603513590	4/15/2019 2:40 PM
Details	Last Recertification Date	Insert	New Registration			4/15/2019 2:40 PM
Details	Grant Number	Insert	New Registration			4/15/2019 2:40 PM
Details	340B ID	Insert	New Registration			4/15/2019 2:40 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/15/2019 2:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/15/2019 2:40 PM
Details	Medicare Provider Number	Insert	New Registration		050342	4/15/2019 2:40 PM
Details	Entity Name	Insert	New Registration		PIONEERS MEM. HOSPITAL	4/15/2019 2:40 PM
Details	Program Code	Insert	New Registration		DSH	4/15/2019 2:40 PM
Details	Entity Subname	Insert	New Registration		Pioneers Children's Health Center	4/15/2019 2:40 PM
Dates	Participating Approval Date	Insert	New Registration			4/15/2019 2:40 PM
Details	State	Insert	New Registration		Pending	4/15/2019 2:40 PM
Dates	Registration Date	Insert	New Registration		4/15/2019 2:40:25 PM	4/15/2019 2:40 PM
Dates	Signed By Date	Insert	New Registration			4/15/2019 2:40 PM
Dates	Start Date	Insert	New Registration			4/15/2019 2:40 PM
Terminations	Termination Comments	Insert	New Registration			4/15/2019 2:40 PM
Terminations	Termination Date	Insert	New Registration			4/15/2019 2:40 PM
Terminations	Termination Effective Date	Insert	New Registration			4/15/2019 2:40 PM
Terminations	Termination Reason	Insert	New Registration			4/15/2019 2:40 PM