| 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 11:42:54 AM | 9/2/2024 10:39:57 AM | 9/2/2024 10:39 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 11:42 AM |
| Addresses | Shipping Address | Delete | Recertification | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N Gantenbein
Portland, OR 97227 | | 9/8/2023 11:42 AM |
| Addresses | Shipping Address | Insert | Recertification | | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N Gantenbein Ave
Portland, OR 97227 | 9/8/2023 11:42 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 1:41:09 PM | 9/8/2023 11:42:54 AM | 9/8/2023 11:42 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2021 7:00:30 PM | 9/8/2022 1:41:09 PM | 9/8/2022 1:41 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:54 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 055103 | 6/13/2022 6:54 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OR | 6/13/2022 6:54 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:54 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 055330 | 6/13/2022 6:54 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OR | 6/13/2022 6:54 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2022 6:54 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1019958 | 6/13/2022 6:54 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | WA | 6/13/2022 6:54 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1831112358 | 6/13/2022 6:54 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | OR | 6/13/2022 6:54 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1831112358 | 6/13/2022 6:54 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | WA | 6/13/2022 6:54 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2020 9:30:13 AM | 9/9/2021 7:00:30 PM | 9/9/2021 7:00 PM |
| 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 |
| Addresses | Main Address | Update | Recertification |
501 N Graham St.
545
Portland, OR 97227 |
501 N Graham St
545
Portland, OR 97227 | 9/8/2020 9:30 AM |
| Details | Last Recertification Date | Update | Recertification | | 9/8/2020 9:30:13 AM | 9/8/2020 9:30 AM |
| Details | Entity Subname | Update | Recertification | Legacy Emanuel Infusion Services IV Clinic - Infusion Therapy | Legacy Emanuel Infusion Services IV Clinic / IV Therapy 150-3716 | 9/8/2020 9:30 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 | Signed By | Insert | New Registration | | Bradley, Carol
SVP and Chief Nursing Officer
Legacy Health
5034155199 | 8/8/2019 11:20 AM |
| Contacts | Primary Contact | Update | New Registration | Agee, Jennifer
Director, Supply Chain
Legacy Health
5039444202 | Valcarlos, Elena
Pharmacy Operations Manager
Legacy Health
5034131321 | 8/8/2019 11:20 AM |
| Details | 340B ID | Update | New Registration | | DSH380007V | 8/8/2019 11:20 AM |
| Details | Entity Name | Update | New Registration | LEGACY EMANUEL HOSPITAL & HEALTH CTR | LEGACY EMANUEL HOSPITAL & HEALTH CENTER | 8/8/2019 11:20 AM |
| Details | Entity Subname | Update | New Registration | Legacy Emanuel Infusion Services IV Clinic | Legacy Emanuel Infusion Services IV Clinic - Infusion Therapy | 8/8/2019 11:20 AM |
| Dates | Participating Approval Date | Update | New Registration | | 8/8/2019 11:20:56 AM | 8/8/2019 11:20 AM |
| Details | State | Update | New Registration | Pending | Approved | 8/8/2019 11:20 AM |
| Dates | Signed By Date | Update | New Registration | | 8/6/2019 1:13:30 PM | 8/8/2019 11:20 AM |
| Dates | Start Date | Update | New Registration | | 10/1/2019 12:00:00 AM | 8/8/2019 11:20 AM |
| Addresses | Main Address | Insert | New Registration | |
501 N Graham St.
545
Portland, OR 97227 | 7/11/2019 7:12 PM |
| Addresses | Billing Address | Insert | New Registration | | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N Gantenbein
Portland, OR 97227 | 7/11/2019 7:12 PM |
| Addresses | Shipping Address | Insert | New Registration | | LEGACY EMANUEL HOSPITAL & HEALTH CTR
2801 N Gantenbein
Portland, OR 97227 | 7/11/2019 7:12 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Bradley, Carol
SVP and Chief Nursing Officer
Legacy Health
5034155199 | 7/11/2019 7:12 PM |
| Contacts | Primary Contact | Insert | New Registration | | Agee, Jennifer
Director, Supply Chain
Legacy Health
5039444202 | 7/11/2019 7:12 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Details | Grant Number | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Details | 340B ID | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 380007 | 7/11/2019 7:12 PM |
| Details | Entity Name | Insert | New Registration | | LEGACY EMANUEL HOSPITAL & HEALTH CTR | 7/11/2019 7:12 PM |
| Details | Program Code | Insert | New Registration | | DSH | 7/11/2019 7:12 PM |
| Details | Entity Subname | Insert | New Registration | | Legacy Emanuel Infusion Services IV Clinic | 7/11/2019 7:12 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Details | State | Insert | New Registration | | Pending | 7/11/2019 7:12 PM |
| Dates | Registration Date | Insert | New Registration | | 7/11/2019 7:12:18 PM | 7/11/2019 7:12 PM |
| Dates | Signed By Date | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Dates | Start Date | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Terminations | Termination Date | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 7/11/2019 7:12 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 7/11/2019 7:12 PM |