Covered Entity Details

PED063301-68 Children's Hospital Colorado (Active) - information as of 6/23/2025 12:25:47 AM

Main Details

Name

Children's Hospital Colorado

Subdivision Name

CHILDRENS HOSPITAL COLORADO - North Campus Pediatric Surgery Clinic

Type

Children's Hospital

Rural

340B ID

PED063301-68

Medicare Provider Number

063301

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/14/2020

Participating Start Date

10/1/2020

Participating Approval Date

8/4/2020

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Children's Hospital Colorado
Casey Dugan, Vice President of Pharmacy Services
(720) 777-5683

Primary Contact

Children's Hospital Colorado
Ricardo Alexis Laremont, Pharmacy 340B Program Manager
(720) 777-8899

Addresses

Street Address

469 STATE HIGHWAY 7
BROOMFIELD, CO 80023-8965

Billing Address
Same as Street Address

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
CO	05002043	1336245828,1023867397,1710348214

Shipping Addresses

Same as Street Address

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
PED063301-01	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus Urgent Care	469 State Highway 7	Broomfield	CO	Active
PED063301-02	Child	PED	Children's Hospital Colorado	Urgent Care Uptown Denver	1830 Franklin Street	Denver	CO	Active
PED063301-03	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	Children's Hospital Colorado - Littleton Oncology Clinic	13123 East 16th Avenue	Aurora	CO	Terminated
PED063301-04	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Parker Physical Therapy	19284 Cottonwood Dr	Parker	CO	Active
PED063301-05	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Broomfield Physical Therapy	8401 Arista Place	Broomfield	CO	Active
PED063301-06	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	Children's Hospital Colorado - Memorial Printers Park Peds PT- Outpatient	175 S Union Blvd	Colorado Springs	CO	Terminated
PED063301-07	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	Children's Hospital Colorado - Pueblo Speech Pathology	704 Fortino Blvd	Pueblo	CO	Terminated
PED063301-08	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - KidStreet Therapy Care	860 North Potomac Circle	Aurora	CO	Active
PED063301-09	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Centennial Orthopedic Care	9094 E Mineral Ave	Centennial	CO	Active
PED063301-10	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Village Pavilion 3rd Floor Clinics	860 N Potomac Circle	Aurora	CO	Terminated
PED063301-100	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus Genetics - North Campus Genetics	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-101	Child	PED	Children's Hospital Colorado	Southeast Aurora Genetics	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-102	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus Lifestyle Medicine - North Campus Lifestyle Medicine	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-103	Child	PED	Children's Hospital Colorado	Southeast Aurora ENT	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-104	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus Plastic Surgery - North Campus Plastic Surgery	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-105	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - South Campus Nephrology Clinic - South Campus Nephrology Clinic	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-106	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus Nephrology Clinic - North Campus Nephrology Clinic	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-107	Child	PED	Children's Hospital Colorado	Southeast Aurora Endocrinology	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-108	Child	PED	Children's Hospital Colorado	Southeast Aurora Neurology	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-109	Child	PED	Children's Hospital Colorado	Southeast Aurora Gastro	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-11	Child	PED	Children's Hospital Colorado	Southeast Aurora Clinics	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-110	Child	PED	Children's Hospital Colorado	Southeast Aurora Urology	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-111	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Maternal Fetal Care North - Maternal Fetal Care North	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-112	Child	PED	Children's Hospital Colorado	Southeast Aurora Gynecology	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-113	Child	PED	Children's Hospital Colorado	Southeast Aurora Urgent Care	23770 E. Smoky Hill Rd	Aurora	CO	Active
PED063301-12	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	Children's Hospital Colorado - Centennial OP Specialty Care	13123 East 16th Avenue	Aurora	CO	Terminated
PED063301-13	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	Children's Hospital Colorado - Briargate COS OP Specialty Care	4125 Briargate Parkway	Colorado Springs	CO	Terminated
PED063301-14	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Urgent Care Wheat Ridge	3455 Lutheran Pkwy	Wheat Ridge	CO	Active
PED063301-15	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	Children's Hospital Colorado - Littleton Physical Therapy	151 West County Line Rd	Littleton	CO	Terminated
PED063301-16	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	Children's Hospital Colorado - Briargate COS Orthopedic Care	4125 Briargate Parkway	Colorado Springs	CO	Terminated
PED063301-17	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	Children's Hospital Colorado - Briargate Oncology Clinic	4125 Briargate Parkway	Colorado Springs	CO	Terminated
PED063301-18	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Uptown Clinics	1830 Franklin St.	Denver	CO	Active
PED063301-19	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado / Uptown Orthopedic Care	1830 Franklin St	Denver	CO	Active
PED063301-20	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus OP Specialty Care	469 State Highway 7	Broomfield	CO	Active
PED063301-21	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus Orthopedic Care	469 State Highway 7	Broomfield	CO	Active
PED063301-22	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus Sports Therapy	469 State Highway 7	Broomfield	CO	Active
PED063301-23	Child	PED	Children's Hospital Colorado	Southeast Aurora Orthopedic Care	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-24	Child	PED	Children's Hospital Colorado	Southeast Aurora Sports Therapy	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-25	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - South Campus CCBD	1811 Plaza Dr	Highlands Ranch	CO	Active
PED063301-26	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - South Campus Level 4 OP Specialty	1811 Plaza Dr	Highlands Ranch	CO	Terminated
PED063301-27	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - South Campus Level 3 OP Specialty	1811 Plaza Dr	Highlands Ranch	CO	Active
PED063301-28	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - South Campus Radiology	1811 Plaza Dr	Highlands Ranch	CO	Active
PED063301-29	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - South Campus Sports Therapy	1811 Plaza Dr	Highlands Ranch	CO	Active
PED063301-30	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - South Campus Surgery	1811 Plaza Dr	Highlands Ranch	CO	Active
PED063301-31	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - South Campus Urgent Care	1811 Plaza Dr	Highlands Ranch	CO	Active
PED063301-32	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Outpatient Specialty Care Wheat Ridge	3455 Lutheran Pkwy	Wheat Ridge	CO	Active
PED063301-33	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - Wheat Ridge Orthopedic Care	3455 Lutheran Pkwy	Wheat Ridge	CO	Active
PED063301-34	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	CHILDRENS HOSPITAL COLORADO / Wheatridge Gastro	469 WEST STATE HIGHWAY 7	BROOMFIELD	CO	Terminated
PED063301-35	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / Wheat Ridge Ado Family	3455 LUTHERAN PARKWAY SUITE 230	WHEAT RIDGE	CO	Active
PED063301-36	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / Wheat Ridge ENT	3455 Lutheran Pkwy	WHEAT RIDGE	CO	Active
PED063301-37	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / North Campus Allergy	469 State Highway 7	BROOMFIELD	CO	Active
PED063301-38	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / North Campus ENT	469 State Highway 7	BROOMFIELD	CO	Active
PED063301-39	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / North Campus Dermatology	469 WEST STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-40	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / Uptown Rehab Clinic	1830 FRANKLIN STREET	DENVER	CO	Active
PED063301-41	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / Uptown ENT	1830 Franklin Street	DENVER	CO	Active
PED063301-42	Child	PED	Children's Hospital Colorado	Southeast Aurora Allergy	23770 E. Smoky Hill Rd.	Aurora	CO	Active
PED063301-43	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado / Child Health Clinic HP	860 N Potomac Circle	Aurora	CO	Active
PED063301-44	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado / CO Ado Maternity PR HP	860 N Potomac Circle	Aurora	CO	Active
PED063301-45	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado / Ado Medicine Clinic HP	860 N Potomac Circle	Aurora	CO	Active
PED063301-46	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado / Eye Clinic HP	860 N Potomac Circle	Aurora	CO	Active
PED063301-47	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado / Young Mothers HP	860 N Potomac Circle	Aurora	CO	Active
PED063301-48	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado / Ado Family Planning HP	860 N Potomac Circle	Aurora	CO	Active
PED063301-49	Child	PED	THE CHILDREN'S HOSPITAL ASSOCIATION	CHILDRENS HOSPITAL COLORADO / Broomfield OP Specialty Care	8401 ARISTA PLACE	BROOMFIELD	CO	Terminated
PED063301-50	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / Broomfield Rehab Psych	8401 ARISTA PLACE	BROOMFIELD	CO	Active
PED063301-51	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Eye Clinic	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-52	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Rehab Clinic	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-53	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Urology	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-54	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Endo	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-55	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South BDC	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-56	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Gynecology	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-57	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Dermatology	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-58	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Gastro	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-59	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Ado Family	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-60	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Allergy	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-61	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South ENT	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-62	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Campus Rehab Psych	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-63	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Ortho	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-64	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Neurology	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-65	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO / South Campus Cardiology	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-66	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Parker Emergency Department	9395 CROWN CREST BOULEVARD	PARKER	CO	Terminated
PED063301-67	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Uptown Sleep Lab	1830 N FRANKLIN ST	DENVER	CO	Active
PED063301-68	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus Pediatric Surgery Clinic	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-69	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Uptown Gastro	1830 N FRANKLIN ST	DENVER	CO	Active
PED063301-70	Child	PED	Children's Hospital Colorado	CHILDREN'S COLORADO - HEALTH PAVILI - Health Pavilion Wellness Center	860 N POTOMAC CIRCLE	AURORA	CO	Active
PED063301-71	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Pulmonary	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-72	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus Radiology	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-73	Child	PED	Children's Hospital Colorado	CHILDREN'S COLORADO - HEALTH PAVILI - Health Pavilion Outpatient Physical Therapy	860 N POTOMAC CIRCLE	AURORA	CO	Active
PED063301-74	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Uptown Cardiology Clinic	1830 N FRANKLIN ST	DENVER	CO	Active
PED063301-75	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Uptown Allergy	1830 N FRANKLIN ST	DENVER	CO	Active
PED063301-76	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Urology	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-77	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus Rehab Clinic	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-78	Child	PED	Children's Hospital Colorado	CHILDREN'S COLORADO - HEALTH PAVILI - Health Pavilion TRUE Center	860 N POTOMAC CIRCLE	AURORA	CO	Active
PED063301-79	Child	PED	Children's Hospital Colorado	CHILDREN'S COLORADO - HEALTH PAVILI - Health Pavilion Orthopedic Clinic	860 N POTOMAC CIRCLE	AURORA	CO	Active
PED063301-80	Child	PED	Children's Hospital Colorado	CHILDREN'S COLORADO - HEALTH PAVILI - Health Pavilion Eye Care CO	860 N POTOMAC CIRCLE	AURORA	CO	Active
PED063301-81	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Uptown Endocrinology	1830 N FRANKLIN ST	DENVER	CO	Active
PED063301-82	Child	PED	Children's Hospital Colorado	CHILDREN'S COLORADO - HEALTH PAVILI - Health Pavilion Pulmonary Clinic	860 N POTOMAC CIRCLE	AURORA	CO	Active
PED063301-83	Child	PED	Children's Hospital Colorado	CHILDREN'S COLORADO - HEALTH PAVILI - Health Pavilion CHIP Youth Program	860 N POTOMAC CIRCLE	AURORA	CO	Active
PED063301-84	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus Endocrinology	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-85	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - South Pulmonary	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-86	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Cardiology	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-87	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Wheat Ridge Cardiology	3455 LUTHERAN PKWY	WHEAT RIDGE	CO	Active
PED063301-88	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Wheat Ridge Dermatology	3455 LUTHERAN PKWY	WHEAT RIDGE	CO	Active
PED063301-89	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Wheat Ridge Endocrinology	3455 LUTHERAN PKWY	WHEAT RIDGE	CO	Active
PED063301-90	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus CCBD Infusion	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-91	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - Wheat Ridge Gastro	3455 LUTHERAN PKWY	WHEAT RIDGE	CO	Active
PED063301-92	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - South Rheumatology	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-93	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Gastro	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-94	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - South Campus Sleep Lab	1811 PLAZA DRIVE	HIGHLANDS RANCH	CO	Active
PED063301-95	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus Eye Clinic	469 State Highway 7	Broomfield	CO	Active
PED063301-96	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus Rheumatology	469 State Highway 7	Broomfield	CO	Active
PED063301-97	Child	PED	Children's Hospital Colorado	Children's Hospital Colorado - North Campus Gynecology	469 State Highway 7	Broomfield	CO	Active
PED063301-98	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus Neurology	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active
PED063301-99	Child	PED	Children's Hospital Colorado	CHILDRENS HOSPITAL COLORADO - North Campus Adolescent Family Planning	469 STATE HIGHWAY 7	BROOMFIELD	CO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 2:22:46 PM	9/4/2024 5:23:04 PM	9/4/2024 5:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1710348214	8/7/2024 6:01 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	8/7/2024 6:01 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1023867397	5/21/2024 7:24 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CO	5/21/2024 7:24 PM
Details	Last Recertification Date	Update	Recertification	9/12/2022 9:44:29 AM	8/23/2023 2:22:46 PM	8/23/2023 2:22 PM
Details	Last Recertification Date	Update	Recertification	9/6/2021 1:55:18 PM	9/12/2022 9:44:29 AM	9/12/2022 9:44 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1336245828 ( )		9/6/2021 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1336245828	9/6/2021 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/6/2021 1:55 PM
Details	Last Recertification Date	Update	Recertification		9/6/2021 1:55:18 PM	9/6/2021 1:55 PM
Contacts	Primary Contact	Update	Profile Change Request	Laremont, Ricardo Alexis Pharmacy 340B Coordinator Children's Hospital Colorado 7207778899	Laremont, Ricardo Alexis Pharmacy 340B Program Manager Children's Hospital Colorado 7207778899	6/23/2021 11:54 AM
Details	State	Update		Approved	Active	10/1/2020 12:01 AM
Contacts	Signed By	Insert	New Registration		Dugan, Casey Vice President of Pharmacy Services Children's Hospital Colorado 7207775683	8/4/2020 8:22 AM
Details	340B ID	Update	New Registration		PED063301-68	8/4/2020 8:22 AM
Details	Entity Name	Update	New Registration	CHILDRENS HOSPITAL COLORADO	Children's Hospital Colorado	8/4/2020 8:22 AM
Details	Entity Subname	Update	New Registration	CHILDRENS HOSPITAL COLORADO	CHILDRENS HOSPITAL COLORADO - North Campus Pediatric Surgery Clinic	8/4/2020 8:22 AM
Dates	Participating Approval Date	Update	New Registration		8/4/2020 8:22:58 AM	8/4/2020 8:22 AM
Details	State	Update	New Registration	Pending	Approved	8/4/2020 8:22 AM
Dates	Signed By Date	Update	New Registration		7/14/2020 6:31:30 PM	8/4/2020 8:22 AM
Dates	Start Date	Update	New Registration		10/1/2020 12:00:00 AM	8/4/2020 8:22 AM
Addresses	Main Address	Insert	New Registration		469 STATE HIGHWAY 7 BROOMFIELD, CO 80023-8965	7/14/2020 4:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/14/2020 4:06 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		05002043	7/14/2020 4:06 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	7/14/2020 4:06 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1336245828	7/14/2020 4:06 PM
Contacts	Primary Contact	Insert	New Registration		Laremont, Ricardo Alexis Pharmacy 340B Coordinator Children's Hospital Colorado 7207778899	7/14/2020 4:06 PM
Contacts	Authorizing Official	Insert	New Registration		Dugan, Casey Vice President of Pharmacy Services Children's Hospital Colorado 7207775683	7/14/2020 4:06 PM
Details	Last Recertification Date	Insert	New Registration			7/14/2020 4:06 PM
Details	Grant Number	Insert	New Registration			7/14/2020 4:06 PM
Details	340B ID	Insert	New Registration			7/14/2020 4:06 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/14/2020 4:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/14/2020 4:06 PM
Details	Medicare Provider Number	Insert	New Registration		063301	7/14/2020 4:06 PM
Details	Entity Name	Insert	New Registration		CHILDRENS HOSPITAL COLORADO	7/14/2020 4:06 PM
Details	Program Code	Insert	New Registration		PED	7/14/2020 4:06 PM
Details	Entity Subname	Insert	New Registration		CHILDRENS HOSPITAL COLORADO	7/14/2020 4:06 PM
Dates	Participating Approval Date	Insert	New Registration			7/14/2020 4:06 PM
Details	State	Insert	New Registration		Pending	7/14/2020 4:06 PM
Dates	Registration Date	Insert	New Registration		7/14/2020 4:06:03 PM	7/14/2020 4:06 PM
Dates	Signed By Date	Insert	New Registration			7/14/2020 4:06 PM
Dates	Start Date	Insert	New Registration			7/14/2020 4:06 PM
Terminations	Termination Comments	Insert	New Registration			7/14/2020 4:06 PM
Terminations	Termination Date	Insert	New Registration			7/14/2020 4:06 PM
Terminations	Termination Effective Date	Insert	New Registration			7/14/2020 4:06 PM
Terminations	Termination Reason	Insert	New Registration			7/14/2020 4:06 PM