Covered Entity Details

RRC050283-00 STANFORD HEALTH CARE TRI-VALLEY (Active) - information as of 6/12/2025 6:01:37 AM

Main Details

Name

STANFORD HEALTH CARE TRI-VALLEY

Subdivision Name

Type

Rural Referral Center

Rural

Yes

340B ID

RRC050283-00

Medicare Provider Number

050283

Additional Details

Current Program Status

Active

Registration Date

7/1/2022

Participating Start Date

10/1/2022

Participating Approval Date

7/7/2022

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Stanford Health Care Tri-Valley
Kyle Wichelmann, CFO
(925) 373-8087

Primary Contact

Stanford Health Care - Tri-Valley
Elizabeth Ledezma, 340B Specialist
(818) 434-1677

Addresses

Street Address

5555 W. LAS POSITAS BOULEVARD
PLEASANTON, CA 94588

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating Start Date 10/1/2021, Termination Date 10/1/2021, Reinstatement 10/1/2022	07/07/2022

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
NV		1144389941
TX		1144389941
CO		1144389941
OR		1144389941
AZ		1144389941
UT		1144389941
PA		1144389941
LA		1144389941
CA		1144389941
NY		1144389941
WA		1144389941

Shipping Addresses

Shipping Address 1

Stanford Health Care - Tri-Valley Pharmacy 3rd Floor
5555 W Las Positas Blvd FL3
Pleasanton, CA 94588-4000

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
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (KS)		6/11/2025 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	6/11/2025 6:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	6/11/2025 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	6/11/2025 6:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	6/11/2025 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	6/11/2025 6:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	6/11/2025 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	6/11/2025 6:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	6/11/2025 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	6/11/2025 6:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	6/11/2025 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	6/11/2025 6:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	6/11/2025 6:54 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	6/11/2025 6:54 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	6/11/2025 6:54 PM
Addresses	Shipping Address	Insert	Change Request		Stanford Health Care - Tri-Valley Pharmacy 3rd Floor 5555 W Las Positas Blvd FL3 Pleasanton, CA 94588-4000	4/2/2025 8:25 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (CO)		3/11/2025 11:55 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (VA)		3/11/2025 11:55 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (DC)		3/11/2025 11:55 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (TX)		3/11/2025 11:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/11/2025 11:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	3/11/2025 11:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/11/2025 11:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		OR	3/11/2025 11:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/11/2025 11:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		KS	3/11/2025 11:55 AM
Contacts	Authorizing Official	Update	Profile Change Request	Wichelmann, Kyle CFO The Hospital Committee for the Livermore-Pleasanton Areas 9253738087	Wichelmann, Kyle CFO Stanford Health Care Tri-Valley 9253738087	3/11/2025 6:23 AM
Contacts	Signed By	Update	Profile Change Request	Wichelmann, Kyle CFO The Hospital Committee for the Livermore-Pleasanton Areas 9253738087	Wichelmann, Kyle CFO Stanford Health Care Tri-Valley 9253738087	3/11/2025 6:23 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (AL)		12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (AZ)		12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (FL)		12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (ID)		12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (MI)		12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (NJ)		12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (NC)		12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (OK)		12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	12/12/2024 4:05 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	12/12/2024 4:05 PM
Medicaid Billing	NPI: State	Insert	Change Request		DC	12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	12/12/2024 4:05 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/12/2024 4:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (NY)		9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (WA)		9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	9/12/2024 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	9/12/2024 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	9/12/2024 3:42 PM
Details	Last Recertification Date	Update	Recertification	8/26/2023 4:00:05 PM	8/20/2024 12:41:58 PM	8/20/2024 12:41 PM
Details	Entity Name	Update	Recertification	VALLEY MEMORIAL HOSPITAL	STANFORD HEALTH CARE TRI-VALLEY	8/20/2024 12:41 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (MA)		6/12/2024 3:00 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (NV)		6/12/2024 3:00 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (AL)		6/12/2024 3:00 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (GA)		6/12/2024 3:00 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (LA)		6/12/2024 3:00 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (OR)		6/12/2024 3:00 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (PA)		6/12/2024 3:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	6/12/2024 3:00 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	6/12/2024 3:00 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (CO)		3/13/2024 8:48 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1144389941 (TX)		3/13/2024 8:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/13/2024 8:48 AM
Medicaid Billing	NPI: State	Insert	Change Request		AL	3/13/2024 8:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/13/2024 8:48 AM
Medicaid Billing	NPI: State	Insert	Change Request		GA	3/13/2024 8:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/13/2024 8:48 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	3/13/2024 8:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/13/2024 8:48 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	3/13/2024 8:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/13/2024 8:48 AM
Medicaid Billing	NPI: State	Insert	Change Request		OR	3/13/2024 8:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	3/13/2024 8:48 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	3/13/2024 8:48 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	12/13/2023 2:58 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	12/13/2023 2:58 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	12/13/2023 2:58 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	12/13/2023 2:58 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	12/13/2023 2:58 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	12/13/2023 2:58 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144389941	12/13/2023 2:58 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	12/13/2023 2:58 PM
Contacts	Primary Contact	Update	Change Request	mulamalla, Hari Chandana Reddy Director of Pharmacy Stanford health care-valley care 3122150088	Ledezma, Elizabeth 340B Specialist Stanford Health Care - Tri-Valley 8184341677	9/7/2023 1:21 PM
Details	Last Recertification Date	Update	Recertification		8/26/2023 4:00:05 PM	8/26/2023 4:00 PM
Details	State	Update		Approved	Active	10/1/2022 12:01 AM
Addresses	Main Address	Update	Reinstatement	1111 EAST STANLEY BLVD LIVERMORE, CA 94550	5555 W. LAS POSITAS BOULEVARD PLEASANTON, CA 94588	7/7/2022 7:24 AM
Contacts	Primary Contact	Update	Reinstatement	NAOTUNNE, BHARATHA Assistant Director The Hospital Committee for the Livermore-Pleasanton Areas 9254139849	mulamalla, Hari Chandana Reddy Director of Pharmacy Stanford health care-valley care 3122150088	7/7/2022 7:24 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	9/21/2021 12:00:00 AM		7/7/2022 7:24 AM
Dates	Participating Approval Date	Update	Reinstatement	8/2/2021 9:58:46 AM	7/7/2022 7:24:26 AM	7/7/2022 7:24 AM
Details	State	Update	Reinstatement	Terminated	Approved	7/7/2022 7:24 AM
Dates	Registration Date	Update	Reinstatement	7/14/2021 9:02:07 PM	7/1/2022 3:01:26 PM	7/7/2022 7:24 AM
Dates	Signed By Date	Update	Reinstatement	7/30/2021 12:05:42 PM	7/6/2022 8:53:53 PM	7/7/2022 7:24 AM
Dates	Start Date	Update	Reinstatement	10/1/2021 12:00:00 AM	10/1/2022 12:00:00 AM	7/7/2022 7:24 AM
Terminations	Termination Comments	Update	Reinstatement	We will resubmit when we have all the infrastructure in place. We did not make any purchases under the program to date.		7/7/2022 7:24 AM
Terminations	Termination Date	Update	Reinstatement	10/1/2021 12:00:00 AM		7/7/2022 7:24 AM
Terminations	Termination Effective Date	Update	Reinstatement	9/21/2021 12:00:00 AM		7/7/2022 7:24 AM
Terminations	Termination Reason	Update	Reinstatement	Never implemented the 340B Program		7/7/2022 7:24 AM
Details	Comments Public	Insert	Reinstatement		Participating Start Date 10/1/2021, Termination Date 10/1/2021, Reinstatement 10/1/2022	7/7/2022 7:19 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/21/2021 12:00:00 AM	9/22/2021 6:49 AM
Details	State	Update	Termination Request	Approved	To Be Terminated	9/22/2021 6:49 AM
Terminations	Termination Comments	Update	Termination Request		We will resubmit when we have all the infrastructure in place. We did not make any purchases under the program to date.	9/22/2021 6:49 AM
Terminations	Termination Date	Update	Termination Request		10/1/2021 12:00:00 AM	9/22/2021 6:49 AM
Terminations	Termination Effective Date	Update	Termination Request		9/21/2021 12:00:00 AM	9/22/2021 6:49 AM
Terminations	Termination Reason	Update	Termination Request		Never implemented the 340B Program	9/22/2021 6:49 AM
Contacts	Signed By	Insert	New Registration		Wichelmann, Kyle CFO The Hospital Committee for the Livermore-Pleasanton Areas 9253738087	8/2/2021 9:58 AM
Details	340B ID	Update	New Registration		RRC050283-00	8/2/2021 9:58 AM
Dates	Participating Approval Date	Update	New Registration		8/2/2021 9:58:46 AM	8/2/2021 9:58 AM
Details	State	Update	New Registration	Pending	Approved	8/2/2021 9:58 AM
Dates	Signed By Date	Update	New Registration		7/30/2021 12:05:42 PM	8/2/2021 9:58 AM
Dates	Start Date	Update	New Registration		10/1/2021 12:00:00 AM	8/2/2021 9:58 AM
Addresses	Main Address	Insert	New Registration		1111 EAST STANLEY BLVD LIVERMORE, CA 94550	7/14/2021 9:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1144389941	7/14/2021 9:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	7/14/2021 9:02 PM
Contacts	Primary Contact	Insert	New Registration		NAOTUNNE, BHARATHA Assistant Director The Hospital Committee for the Livermore-Pleasanton Areas 9254139849	7/14/2021 9:02 PM
Contacts	Authorizing Official	Insert	New Registration		Wichelmann, Kyle CFO The Hospital Committee for the Livermore-Pleasanton Areas 9253738087	7/14/2021 9:02 PM
Details	Assistance Received From Date	Insert	New Registration			7/14/2021 9:02 PM
Details	Assistance Received To Date	Insert	New Registration			7/14/2021 9:02 PM
Details	Last Recertification Date	Insert	New Registration			7/14/2021 9:02 PM
Details	Grant Number	Insert	New Registration			7/14/2021 9:02 PM
Details	340B ID	Insert	New Registration			7/14/2021 9:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/14/2021 9:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/14/2021 9:02 PM
Details	Medicare Provider Number	Insert	New Registration		050283	7/14/2021 9:02 PM
Details	Entity Name	Insert	New Registration		VALLEY MEMORIAL HOSPITAL	7/14/2021 9:02 PM
Details	NOFO Number	Insert	New Registration			7/14/2021 9:02 PM
Details	Program Code	Insert	New Registration		RRC	7/14/2021 9:02 PM
Details	Entity Subname	Insert	New Registration			7/14/2021 9:02 PM
Dates	Participating Approval Date	Insert	New Registration			7/14/2021 9:02 PM
Details	State	Insert	New Registration		Pending	7/14/2021 9:02 PM
Dates	Registration Date	Insert	New Registration		7/14/2021 9:02:07 PM	7/14/2021 9:02 PM
Dates	Signed By Date	Insert	New Registration			7/14/2021 9:02 PM
Dates	Start Date	Insert	New Registration			7/14/2021 9:02 PM
Terminations	Termination Comments	Insert	New Registration			7/14/2021 9:02 PM
Terminations	Termination Date	Insert	New Registration			7/14/2021 9:02 PM
Terminations	Termination Effective Date	Insert	New Registration			7/14/2021 9:02 PM
Terminations	Termination Reason	Insert	New Registration			7/14/2021 9:02 PM