Covered Entity Details

DSH030014Y JOHN C. LINCOLN MEDICAL CENTER (Terminated) - information as of 6/14/2025 10:10:06 AM

Main Details

Name

JOHN C. LINCOLN MEDICAL CENTER

Subdivision Name

JCLMC Infusion Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030014Y

Medicare Provider Number

030014

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/3/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/9/2020

Last Recertification Date

8/24/2020

Termination Date
Termination Reason

7/1/2021
Business decision by the Covered Entity

Contacts

Authorizing Official

HonorHealth
Gary Baker, SVP-CEO-HOSPITAL
(480) 583-0803

Primary Contact

HonorHealth
Kristjon Lindgren, 340B Program Director
(602) 793-5509

Addresses

Street Address

3501 N Scottsdale Rd #136
Scottsdale, AZ 85251

Billing Address

John C. Lincoln Medical Center
PO Box 14890
Scottsdale, AZ 85267

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
AZ	022241	1770690695
AK	HS757IP,HS757OP	1770690695
AL	JOH0014N	1770690695
AR	189215105	1770690695
CA	90367,860181654,XHSP42340,XHSP32340,1386608859,860181654WV,PRV006826,QMP000004946960	1770690695
CO	95190112,860181654	1770690695
CT	003054129,008047201	1770690695
DC	055575200	1770690695
FL	092474100,245412000,860117301,ND895,1326503	1770690695
GA	003176592A,003116091A,000487946X,NR - REVAL,003176648A,860181654,N1425	1770690695
IA	02885297,0983767,1983767	1770690695
ID	002925100	1770690695
IL	N1425,860181654,860181654006,860117301001	1770690695
IN	860181654,201035820A,300042446	1770690695
KS	100100590C,860181654,02885297	1770690695
KY	01220136,0122013600,ND895,N1425,N1098839	1770690695
LA	60065488,10025901,1749982	1770690695
MA	0964397,35974,110027159A,110027159B	1770690695
MD	02885297,70025901,488644,860181654,531209400	1770690695
ME	191160000	1770690695
MI	860181654,860117301,30-4908703,40-4908712	1770690695
MN	00500080007,447317500,300969	1770690695
MO	011380201,N1425	1770690695
MS	01074063	1770690695
NC	9300014	1770690695
NE	10026210700	1770690695
NJ	02885297,10025901,60159345	1770690695
NM	860181654,01201026,201080235,24051837	1770690695
NV	001188961,02885297	1770690695
NY	488644,111031000122,860181654,01619396	1770690695
OH	860181654,860117301001,6921880,5187257,860181654D	1770690695
OK	100704870A	1770690695
OR	128579,860117301,860181654	1770690695
PA	30245244,1007457650007,1007632800001,43957,VC9417	1770690695
SC	12148B	1770690695
TN	02885297,0012108,Q013661,0030014	1770690695
TX	02885297,071480001,QMP000005075548	1770690695
UT	1023425,QMP000003687930	1770690695
VA	860181654	1770690695
VT	0030014	1770690695
WA	02885297,151234,1018702,QMP000004937946	1770690695
WI	100056786,80517700,03996805,100102520	1770690695
WV	860181654,9810047000	1770690695
HI	860181654	1770690695
DE		1770690695
MT		1770690695
RI		1770690695
WY		1770690695

Shipping Addresses

Shipping Address 1

John C. Lincoln Medical Center
3501 N Scottsdale Rd #230, #280A, #280B
Scottsdale, AZ 85251

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
DSH030014A	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Outpatient / Medical Imaging	9250 N 3rd St #1002	Phoenix	AZ	Terminated
DSH030014AA	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Wound Clinic OP	9202 N 2nd St #101	Phoenix	AZ	Active
DSH030014AB	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Pulmonary Hypertension Clinic	9250 N 3rd St #2030	Phoenix	AZ	Active
DSH030014AC	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Virginia G Piper CCN-Apache Junction	750 S Ironwood Dr #102	Apache Junction	AZ	Terminated
DSH030014AD	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Biltmore	2222 E Highland Ave #400	Phoenix	AZ	Active
DSH030014AE	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Tempe	7695 S Research Dr	Tempe	AZ	Active
DSH030014AF	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - GynOnc Shea	10197 N 92nd St #101	Scottsdale	AZ	Active
DSH030014AG	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	BMT Outpatient	10460 N 92nd St #300	Scottsdale	AZ	Active
DSH030014AH	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HHRI Oncology Clinical Trials	10510 N 92nd St	Scottsdale	AZ	Active
DSH030014AJ	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Home Health	3634 N Drinkwater Blvd	Scottsdale	AZ	Active
DSH030014B	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	John C Lincoln Outpatient Imaging - 27th Ave. / Medical Imaging	19636 N 27th Ave. #LL1	Phoenix	AZ	Terminated
DSH030014C	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	OR Outpatient Surgery	9250 N 3rd St #1001	Phoenix	AZ	Active
DSH030014D	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	John C Lincoln-Tatum / Outpatient Medical Imaging	18404 N Tatum Blvd. #103	Phoenix	AZ	Terminated
DSH030014E	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Infusion Center-Glendale	6220 W Bell Rd #110	Glendale	AZ	Active
DSH030014F	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Pharmacy Care Coordination	9109 North Central Avenue	Phoenix	AZ	Terminated
DSH030014G	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Comprehensive Care Clinic / Outpatient Center	9225 North 3rd Street	Phoenix	AZ	Terminated
DSH030014H	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Comprehensive Care Center / Senior Support Services	9225 N 3rd St	Phoenix	AZ	Terminated
DSH030014J	Child	DSH	JOHN C LINCOLN MEDICAL CENTER	Happy Valley Infusion Care Clinic	10230 W. Happy Valley Parkway	Peoria	AZ	Terminated
DSH030014K	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - John C. Lincoln	9250 N 3rd St #3010	Phoenix	AZ	Active
DSH030014L	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Deer Valley	19646 N 27th Ave #301	Phoenix	AZ	Active
DSH030014M	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	OR Preop/PACU - OP	9250 N 3rd St #1001	Phoenix	AZ	Active
DSH030014N	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Osborn	3621 N Wells Fargo Ave	Scottsdale	AZ	Active
DSH030014P	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Gilbert	3645 S Rome St #209	Gilbert	AZ	Active
DSH030014Q	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Chandler	1110 S Dobson Rd #1	Chandler	AZ	Active
DSH030014R	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Thompson Peak	20745 N Scottsdale Rd #115	Scottsdale	AZ	Active
DSH030014S	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Avondale	10320 W McDowell Rd Bldg H	Avondale	AZ	Active
DSH030014T	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Surprise	14674 W Mountain View Blvd #105	Surprise	AZ	Active
DSH030014U	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Virginia G Piper Cancer Care Network-Wickenburg	519 Rose Ln	Wickenburg	AZ	Terminated
DSH030014V	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Fountain Hills	16716 E Palisades Blvd #103	Fountain Hills	AZ	Active
DSH030014W	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Glendale	15000 N 83rd Ave #300	Peoria	AZ	Active
DSH030014X	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	HonorHealth Cancer Care - Shea	10460 N 92nd St #200 and #400	Scottsdale	AZ	Active
DSH030014Y	Child	DSH	JOHN C. LINCOLN MEDICAL CENTER	JCLMC Infusion Center	3501 N Scottsdale Rd #136	Scottsdale	AZ	Terminated
DSH030014Z	Child	DSH	HONORHEALTH JOHN C. LINCOLN MED CTR	Infusion Center - NSI	7242 E Osborn Rd #340, #400, and #500	Scottsdale	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Lindgren, Kristjon 340B Program Manager HonorHealth 6027935509	Lindgren, Kristjon 340B Program Director HonorHealth 6027935509	9/10/2022 7:07 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		6/5/2021 12:00:00 AM	6/15/2021 8:26 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/15/2021 8:26 AM
Terminations	Termination Date	Update	Termination Request		7/1/2021 12:00:00 AM	6/15/2021 8:26 AM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2021 12:00:00 AM	6/15/2021 8:26 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	6/15/2021 8:26 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1326503	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1983767	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100102520	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	3/15/2021 7:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	QMP0000049379 (WA)		12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300042446	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		02885297	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NV	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		VC9417	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		QMP000004937946	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	12/15/2020 7:12 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	02885297 (IN)		9/15/2020 6:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/15/2020 6:44 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		02885297	9/15/2020 6:44 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	9/15/2020 6:44 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	QMP0000049469 (CA)		9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	QMP0000050755 (TX)		9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	QMP0000036879 (UT)		9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		QMP000004946960	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		860181654	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		HI	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		QMP000005075548	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		QMP000003687930	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03996805	9/14/2020 11:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	9/14/2020 11:55 PM
Addresses	Billing Address	Update	Recertification	John C. Lincoln Medical Center 250 E Dunlap Ave Scottsdale, AZ 85020	John C. Lincoln Medical Center PO Box 14890 Scottsdale, AZ 85267	8/24/2020 4:43 PM
Addresses	Shipping Address	Insert	Recertification		John C. Lincoln Medical Center 3501 N Scottsdale Rd #230, #280A, #280B Scottsdale, AZ 85251	8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (AK)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (AL)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (AR)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (CA)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (CO)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (DE)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (FL)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (GA)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (HI)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (IA)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (ID)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (IL)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (IN)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (KS)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (KY)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (LA)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (MA)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (MD)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (ME)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (MI)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (MN)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (MO)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (MS)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (MT)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (NC)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (NE)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (NJ)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (NM)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (NV)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (NY)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (OH)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (OR)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (PA)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (RI)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (TN)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (TX)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (UT)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (VA)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (WA)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (WI)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (WV)		8/24/2020 4:43 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1770690695 (WY)		8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1770690695 ( )		8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NV	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		VT	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		KS	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		OK	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		AK	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		AR	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		DE	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		HI	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		MT	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		RI	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		WV	8/24/2020 4:43 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770690695	8/24/2020 4:43 PM
Medicaid Billing	NPI: State	Insert	Recertification		WY	8/24/2020 4:43 PM
Details	Last Recertification Date	Update	Recertification		8/24/2020 4:43:13 PM	8/24/2020 4:43 PM
Details	Entity Subname	Update	Recertification	JCLMC Infusion Center - JCLMC Infusion Center	JCLMC Infusion Center	8/24/2020 4:43 PM
Details	Entity Name	Update	Recertification	JOHN C LINCOLN MEDICAL CENTER	JOHN C. LINCOLN MEDICAL CENTER	8/21/2020 11:25 AM
Contacts	Primary Contact	Update	Profile Change Request	Lindgren, Kristjon 340B Program Manager HonorHealth 6028706060-331353	Lindgren, Kristjon 340B Program Manager HonorHealth 6027935509	8/18/2020 10:18 PM
Addresses	Main Address	Update	Change Request	3501 N Scottsdale Rd #300 Scottsdale, AZ 85251	3501 N Scottsdale Rd #136 Scottsdale, AZ 85251	7/1/2020 9:24 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		N1098839	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		24051837	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		43957	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		QMP0000036879	5/30/2020 8:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	5/30/2020 8:45 PM
Contacts	Signed By	Insert	New Registration		Baker, Gary SVP-CEO-HOSPITAL HonorHealth 4805830803	4/9/2020 11:53 AM
Details	340B ID	Update	New Registration		DSH030014Y	4/9/2020 11:53 AM
Details	Entity Subname	Update	New Registration	JCLMC Infusion Center	JCLMC Infusion Center - JCLMC Infusion Center	4/9/2020 11:53 AM
Dates	Participating Approval Date	Update	New Registration		4/9/2020 11:53:14 AM	4/9/2020 11:53 AM
Details	State	Update	New Registration	Pending	Approved	4/9/2020 11:53 AM
Dates	Signed By Date	Update	New Registration		4/8/2020 11:13:38 AM	4/9/2020 11:53 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/9/2020 11:53 AM
Addresses	Main Address	Insert	New Registration		3501 N Scottsdale Rd #300 Scottsdale, AZ 85251	4/3/2020 7:38 PM
Addresses	Billing Address	Insert	New Registration		John C. Lincoln Medical Center 250 E Dunlap Ave Scottsdale, AZ 85020	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		022241	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HS757IP	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HS757OP	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		JOH0014N	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		189215105	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		90367	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		XHSP42340	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		XHSP32340	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1386608859	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654WV	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		PRV006826	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		QMP0000049469	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		95190112	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003054129	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		008047201	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		055575200	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		DC	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		DE	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		092474100	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		245412000	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ND895	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003176592A	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003116091A	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000487946X	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		NR - REVAL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003176648A	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1425	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		HI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0983767	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ID	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		002925100	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ID	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1425	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654006	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301001	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		201035820A	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100100590C	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01220136	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0122013600	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ND895	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1425	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		60065488	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10025901	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1749982	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0964397	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		35974	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110027159A	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110027159B	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		70025901	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		488644	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		531209400	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		191160000	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30-4908703	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		40-4908712	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00500080007	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		447317500	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		300969	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		011380201	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1425	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01074063	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MT	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9300014	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10026210700	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10025901	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		60159345	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01201026	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		201080235	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		001188961	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		488644	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		111031000122	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01619396	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301001	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		6921880	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		5187257	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654D	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100704870A	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		128579	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30245244	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007457650007	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007632800001	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		RI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		12148B	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0012108	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		Q013661	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0030014	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		QMP0000050755	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		071480001	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1023425	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0030014	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		151234	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		QMP0000049379	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1018702	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100056786	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		80517700	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9810047000	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WY	4/3/2020 7:38 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	4/3/2020 7:38 PM
Contacts	Primary Contact	Insert	New Registration		Lindgren, Kristjon 340B Program Manager HonorHealth 6028706060-331353	4/3/2020 7:38 PM
Contacts	Authorizing Official	Insert	New Registration		Baker, Gary SVP-CEO-HOSPITAL HonorHealth 4805830803	4/3/2020 7:38 PM
Details	Last Recertification Date	Insert	New Registration			4/3/2020 7:38 PM
Details	Grant Number	Insert	New Registration			4/3/2020 7:38 PM
Details	340B ID	Insert	New Registration			4/3/2020 7:38 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/3/2020 7:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/3/2020 7:38 PM
Details	Medicare Provider Number	Insert	New Registration		030014	4/3/2020 7:38 PM
Details	Entity Name	Insert	New Registration		JOHN C LINCOLN MEDICAL CENTER	4/3/2020 7:38 PM
Details	Program Code	Insert	New Registration		DSH	4/3/2020 7:38 PM
Details	Entity Subname	Insert	New Registration		JCLMC Infusion Center	4/3/2020 7:38 PM
Dates	Participating Approval Date	Insert	New Registration			4/3/2020 7:38 PM
Details	State	Insert	New Registration		Pending	4/3/2020 7:38 PM
Dates	Registration Date	Insert	New Registration		4/3/2020 7:38:18 PM	4/3/2020 7:38 PM
Dates	Signed By Date	Insert	New Registration			4/3/2020 7:38 PM
Dates	Start Date	Insert	New Registration			4/3/2020 7:38 PM
Terminations	Termination Comments	Insert	New Registration			4/3/2020 7:38 PM
Terminations	Termination Date	Insert	New Registration			4/3/2020 7:38 PM
Terminations	Termination Effective Date	Insert	New Registration			4/3/2020 7:38 PM
Terminations	Termination Reason	Insert	New Registration			4/3/2020 7:38 PM