| Contacts | Authorizing Official | Update | Change Request | Tanas, Majid
VP Pharmacy Services
Legacy Health
5034155011 | Kelly, Kecia
SVP Chief Nursing Officer
Legacy Health
5034155199 | 9/12/2024 11:17 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2023 11:43:13 AM | 9/2/2024 10:30:49 AM | 9/2/2024 10:30 AM |
| Addresses | Main Address | Update | Recertification |
501 N Graham St.
Portland, OR 97227 |
501 N Graham St
Portland, OR 97227 | 9/8/2023 11:43 AM |
| Addresses | Billing Address | Update | Recertification | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N. Gantenbein
Portland, OR 97227 | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N Gantenbein Ave
Portland, OR 97227 | 9/8/2023 11:43 AM |
| Addresses | Shipping Address | Delete | Recertification | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N. Gantenbein
Portland, OR 97227 | | 9/8/2023 11:43 AM |
| Addresses | Shipping Address | Insert | Recertification | | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N Gantenbein Ave
Portland, OR 97227 | 9/8/2023 11:43 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 7:12:19 PM | 9/8/2023 11:43:13 AM | 9/8/2023 11:43 AM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2021 9:49:23 AM | 9/8/2022 7:12:19 PM | 9/8/2022 7:12 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:57 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 055103 | 6/13/2022 6:57 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OR | 6/13/2022 6:57 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:57 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 055330 | 6/13/2022 6:57 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OR | 6/13/2022 6:57 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:57 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1019958 | 6/13/2022 6:57 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | WA | 6/13/2022 6:57 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1831112358 | 6/13/2022 6:57 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | OR | 6/13/2022 6:57 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1831112358 | 6/13/2022 6:57 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | WA | 6/13/2022 6:57 PM |
| Details | Last Recertification Date | Update | Recertification | 9/15/2020 8:29:44 AM | 9/10/2021 9:49:23 AM | 9/10/2021 9:49 AM |
| Details | Entity Subname | Update | Recertification | Legacy Emanuel Cardiopulmonary - Respiratory Therapy 150-3110 | Legacy Emanuel Cardiopulmonary / Respiratory Therapy 150-3110 | 9/10/2021 9:49 AM |
| Contacts | Authorizing Official | Update | Change Request | Loomis, Anna
SVP Chief Financial Officer
Legacy Health
5034155730 | Tanas, Majid
VP Pharmacy Services
Legacy Health
5034155011 | 1/11/2021 8:00 AM |
| Details | Last Recertification Date | Update | Recertification | | 9/15/2020 8:29:44 AM | 9/15/2020 8:29 AM |
| Details | Entity Subname | Update | Recertification | Legacy Emanuel Cardiopulmonary - Cardiology | Legacy Emanuel Cardiopulmonary - Respiratory Therapy 150-3110 | 9/15/2020 8:29 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034137764 | Valcarlos, Elena
Pharmacy Systems Manager
Legacy Health
5034137764 | 1/31/2020 4:08 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034131321 | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034137764 | 1/31/2020 4:08 PM |
| Details | State | Update | | Approved | Active | 10/1/2019 12:04 AM |
| Contacts | Authorizing Official | Update | Change Request | Bradley, Carol
SVP and Chief Nursing Officer
Legacy Health
5034155199 | Loomis, Anna
SVP Chief Financial Officer
Legacy Health
5034155730 | 9/16/2019 5:17 AM |
| Contacts | Primary Contact | Update | Change Request | Agee, Jennifer
Director, Supply Chain
Legacy Health
5039444202 | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034131321 | 8/8/2019 7:25 AM |
| Contacts | Signed By | Insert | New Registration | | Bradley, Carol
SVP and Chief Nursing Officer
Legacy Health
5034155199 | 8/5/2019 7:43 AM |
| Details | 340B ID | Update | New Registration | | DSH380007S | 8/5/2019 7:43 AM |
| Details | Entity Name | Update | New Registration | LEGACY EMANUEL HOSPITAL & HEALTH CTR | LEGACY EMANUEL HOSPITAL & HEALTH CENTER | 8/5/2019 7:43 AM |
| Details | Entity Subname | Update | New Registration | Legacy Emanuel Cardiopulmonary | Legacy Emanuel Cardiopulmonary - Cardiology | 8/5/2019 7:43 AM |
| Dates | Participating Approval Date | Update | New Registration | | 8/5/2019 7:43:41 AM | 8/5/2019 7:43 AM |
| Details | State | Update | New Registration | Pending | Approved | 8/5/2019 7:43 AM |
| Dates | Signed By Date | Update | New Registration | | 7/11/2019 6:37:28 PM | 8/5/2019 7:43 AM |
| Dates | Start Date | Update | New Registration | | 10/1/2019 12:00:00 AM | 8/5/2019 7:43 AM |
| Addresses | Main Address | Insert | New Registration | |
501 N Graham St.
Portland, OR 97227 | 7/11/2019 6:37 PM |
| Addresses | Billing Address | Insert | New Registration | | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N. Gantenbein
Portland, OR 97227 | 7/11/2019 6:37 PM |
| Addresses | Shipping Address | Insert | New Registration | | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N. Gantenbein
Portland, OR 97227 | 7/11/2019 6:37 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Bradley, Carol
SVP and Chief Nursing Officer
Legacy Health
5034155199 | 7/11/2019 6:37 PM |
| Contacts | Primary Contact | Insert | New Registration | | Agee, Jennifer
Director, Supply Chain
Legacy Health
5039444202 | 7/11/2019 6:37 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Details | Grant Number | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Details | 340B ID | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 380007 | 7/11/2019 6:37 PM |
| Details | Entity Name | Insert | New Registration | | LEGACY EMANUEL HOSPITAL & HEALTH CTR | 7/11/2019 6:37 PM |
| Details | Program Code | Insert | New Registration | | DSH | 7/11/2019 6:37 PM |
| Details | Entity Subname | Insert | New Registration | | Legacy Emanuel Cardiopulmonary | 7/11/2019 6:37 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Details | State | Insert | New Registration | | Pending | 7/11/2019 6:37 PM |
| Dates | Registration Date | Insert | New Registration | | 7/11/2019 6:37:24 PM | 7/11/2019 6:37 PM |
| Dates | Signed By Date | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Dates | Start Date | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Terminations | Termination Date | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 7/11/2019 6:37 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 7/11/2019 6:37 PM |