Covered Entity Details

PED053303-33 RADY CHILDRENS HOSPITAL - SAN DIEGO (Terminated) - information as of 6/18/2025 1:08:12 AM

Main Details

Name

RADY CHILDRENS HOSPITAL - SAN DIEGO

Subdivision Name

Gender Affirming Care* - Gender Affirming Care*

Type

Children's Hospital

Rural

340B ID

PED053303-33

Medicare Provider Number

053303

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/13/2021

Participating Start Date

7/1/2021

Participating Approval Date

5/6/2021

Last Recertification Date

8/28/2023

Termination Date
Termination Reason

10/1/2024
Hospital Outpatient facility no longer eligible

Contacts

Authorizing Official

Rady Children's Hospital San Diego
Charles Brendan Davis, Regional President Rady Children's Health San Diego and COO Rady Children's Hospital San Diego
(858) 966-4001

Primary Contact

Rady Children's Hospital San Diego
Chris Abe, VP, Operations
(858) 966-5968

Addresses

Street Address

8110 Birmingham Drive, San Diego, CA 92123
2nd Floor
San Diego, CA 92123

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
CA	1710065933	1710065933,1851303994,1669617197

Shipping Addresses

Shipping Address 1

Rady Children's Hospital - San Diego
3020 Children's Way
San Diego, CA 92123

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
PED053303-01	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Sanford Pediatric Clinic - Urgent Care Oceanside	3605 Vista Way, Suite 172	Oceanside	CA	Active
PED053303-02	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	URGENT CARE MID CITY	4305 UNIVERSITY AVE	SAN DIEGO	CA	Active
PED053303-03	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Urgent Care North County	2125 Citracado Parkway	Escondido	CA	Active
PED053303-04	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Pulmonology	3030 Children's Way	San Diego	CA	Active
PED053303-05	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Urgent Care East County	5565 Grossmont Center Drive, Bldg 2, Suite 2	La Mesa	CA	Terminated
PED053303-06	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Dermatology	7910 Frost Street Suite 120	San Diego	CA	Active
PED053303-07	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Otolaryngology	3030 Children's Way	San Diego	CA	Active
PED053303-08	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Rheumatology / Rheumatology	3030 Children's Way	San Diego	CA	Active
PED053303-10	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Genetics	7920 Frost Street	San Diego	CA	Active
PED053303-11	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Gastroenterology	3030 Children's Way	San Diego	CA	Active
PED053303-14	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Urology	7920 Frost Street	San Diego	CA	Active
PED053303-16	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Orthopedics	3030 Children's Way	San Diego	CA	Active
PED053303-21	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Pediatric Gynecology / Pediatric Gynecology	7920 Frost St Suite #200	San Diego	CA	Active
PED053303-22	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Plastics / Plastics	7920 Frost St Suite #200	San Diego	CA	Active
PED053303-23	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Proton Beam Therapy Clinic	9730 SUMMERS RIDGE RD	SAN DIEGO	CA	Active
PED053303-24	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Pulmonary Function Lab - Pulmonary Function Lab	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-25	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Solid Organ Transplant - Liver Transplant	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-26	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Cystic Fibrosis - Cystic Fibrosis	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-27	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Physiatry - Rehab Medicine	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-28	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Infectious Disease - Infectious Disease	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-29	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Allergy - Allergy	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-30	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Palliative Care and Pain - Supportive Care	Rady Children's Hospital San Diego	San Diego	CA	Terminated
PED053303-31	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Endocrinology - Endocrinology	3030 Children's Way	San Diego	CA	Active
PED053303-32	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	UC South Bay - UC South Bay	386 East H Street	Chula Vista	CA	Active
PED053303-33	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Gender Affirming Care* - Gender Affirming Care*	8110 Birmingham Drive, San Diego, CA 92123	San Diego	CA	Terminated
PED053303-34	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Adolescent Medicine - Adolescent Medicine	8110 Birmingham Drive, San Diego, CA 92123	San Diego	CA	Terminated
PED053303-35	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	RADY CHILDREN'S HOSPITAL - SAN DIEG - Neurology	3030 CHILDRENS WAY	SAN DIEGO	CA	Active
PED053303-36	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Nephrology - Nephrology	3020 Children's Way	San Diego	CA	Active
PED053303-37	Child	PED	RADY CHILDREN'S HOSPITAL SAN DIEGO	Kidney Transplant - Kidney Transplant	3020 Children's Way	San Diego	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Davis, Charles Brendan Interim Chief Operating Officer Rady Children's Hospital San Diego 8589664001	Davis, Charles Brendan Regional President Rady Children's Health San Diego and COO Rady Children's Hospital San Diego Rady Children's Hospital San Diego 8589664001	5/30/2025 6:13 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/1/2024 12:00:00 AM	7/9/2024 3:14 PM
Details	State	Update	Termination Request	Active	To Be Terminated	7/9/2024 3:14 PM
Terminations	Termination Date	Update	Termination Request		10/1/2024 12:00:00 AM	7/9/2024 3:14 PM
Terminations	Termination Effective Date	Update	Termination Request		7/9/2024 12:00:00 AM	7/9/2024 3:14 PM
Terminations	Termination Reason	Update	Termination Request		Hospital Outpatient facility no longer eligible	7/9/2024 3:14 PM
Contacts	Authorizing Official	Update	Change Request	Holmes, Nicholas Matthew Senior VP, Chief Operating Officer Rady Children's Hospital San Diego 8589665948	Davis, Charles Brendan Interim Chief Operating Officer Rady Children's Hospital San Diego 8589664001	2/12/2024 8:32 AM
Addresses	Main Address	Update	Recertification	8110 Birmingham Drive, San Diego, CA 92123 San Diego, CA 92123	8110 Birmingham Drive, San Diego, CA 92123 2nd Floor San Diego, CA 92123	8/28/2023 6:43 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 1:55:33 PM	8/28/2023 6:43:39 AM	8/28/2023 6:43 AM
Contacts	Primary Contact	Update	Change Request	Nguyen, Hoangmy Mimi Pharmacist-In-Chief Rady Children's Hospital San Diego 8585761700-228023	Abe, Chris VP, Operations Rady Children's Hospital San Diego 8589665968	9/16/2022 11:06 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 7:05:13 PM	8/26/2022 1:55:33 PM	8/26/2022 1:55 PM
Details	Last Recertification Date	Update	Recertification		8/16/2021 7:05:13 PM	8/16/2021 7:05 PM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Holmes, Nicholas Matthew Senior VP, Chief Operating Officer Rady Children's Hospital San Diego 8589665948	5/6/2021 2:32 PM
Details	340B ID	Update	New Registration		PED053303-33	5/6/2021 2:32 PM
Details	Entity Subname	Update	New Registration	Gender Affirming Care*	Gender Affirming Care* - Gender Affirming Care*	5/6/2021 2:32 PM
Dates	Participating Approval Date	Update	New Registration		5/6/2021 2:32:54 PM	5/6/2021 2:32 PM
Details	State	Update	New Registration	Pending	Approved	5/6/2021 2:32 PM
Dates	Signed By Date	Update	New Registration		4/30/2021 10:16:05 AM	5/6/2021 2:32 PM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	5/6/2021 2:32 PM
Addresses	Main Address	Insert	New Registration		8110 Birmingham Drive, San Diego, CA 92123 San Diego, CA 92123	4/13/2021 4:23 PM
Addresses	Shipping Address	Insert	New Registration		Rady Children's Hospital - San Diego 3020 Children's Way San Diego, CA 92123	4/13/2021 4:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2021 4:23 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1710065933	4/13/2021 4:23 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/13/2021 4:23 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710065933	4/13/2021 4:23 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/13/2021 4:23 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1851303994	4/13/2021 4:23 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/13/2021 4:23 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1669617197	4/13/2021 4:23 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/13/2021 4:23 PM
Contacts	Authorizing Official	Insert	New Registration		Holmes, Nicholas Matthew Senior VP, Chief Operating Officer Rady Children's Hospital San Diego 8589665948	4/13/2021 4:23 PM
Contacts	Primary Contact	Insert	New Registration		Nguyen, Hoangmy Mimi Pharmacist-In-Chief Rady Children's Hospital San Diego 8585761700-228023	4/13/2021 4:23 PM
Details	Assistance Received From Date	Insert	New Registration			4/13/2021 4:23 PM
Details	Assistance Received To Date	Insert	New Registration			4/13/2021 4:23 PM
Details	Last Recertification Date	Insert	New Registration			4/13/2021 4:23 PM
Details	Grant Number	Insert	New Registration			4/13/2021 4:23 PM
Details	340B ID	Insert	New Registration			4/13/2021 4:23 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/13/2021 4:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/13/2021 4:23 PM
Details	Medicare Provider Number	Insert	New Registration		053303	4/13/2021 4:23 PM
Details	Entity Name	Insert	New Registration		RADY CHILDRENS HOSPITAL - SAN DIEGO	4/13/2021 4:23 PM
Details	NOFO Number	Insert	New Registration			4/13/2021 4:23 PM
Details	Program Code	Insert	New Registration		PED	4/13/2021 4:23 PM
Details	Entity Subname	Insert	New Registration		Gender Affirming Care*	4/13/2021 4:23 PM
Dates	Participating Approval Date	Insert	New Registration			4/13/2021 4:23 PM
Details	State	Insert	New Registration		Pending	4/13/2021 4:23 PM
Dates	Registration Date	Insert	New Registration		4/13/2021 4:23:11 PM	4/13/2021 4:23 PM
Dates	Signed By Date	Insert	New Registration			4/13/2021 4:23 PM
Dates	Start Date	Insert	New Registration			4/13/2021 4:23 PM
Terminations	Termination Comments	Insert	New Registration			4/13/2021 4:23 PM
Terminations	Termination Date	Insert	New Registration			4/13/2021 4:23 PM
Terminations	Termination Effective Date	Insert	New Registration			4/13/2021 4:23 PM
Terminations	Termination Reason	Insert	New Registration			4/13/2021 4:23 PM