Covered Entity Details

DSH050496 JOHN MUIR MEDICAL CENTER - CONCORD (Active) - information as of 4/30/2025 10:50:10 PM

Main Details

Name

JOHN MUIR MEDICAL CENTER - CONCORD

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050496

Medicare Provider Number

050496

Additional Details

Current Program Status

Active

Registration Date

10/3/2022

Participating Start Date

1/1/2023

Participating Approval Date

12/2/2022

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

John Muir Health
Zach Harris, VP Ancillary Services
(808) 457-0157

Primary Contact

John Muir Health
Nikolai Tyler Dahl, Program Manager - Medication Utilization
(925) 947-3243

Addresses

Street Address

2540 EAST STREET
CONCORD, CA 94520

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 7/1/2022, Terminated 10/1/2022, reinstating on 1/1/2023	12/02/2022

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
CA	HSP40496G	1801821376

Shipping Addresses

Shipping Address 1

JOHN MUIR MEDICAL CENTER - CONCORD
2540 EAST STREET
Concord, CA 94520

Shipping Address 2

Pavilion Pharmacy at John Muir Health
177 La Casa Via
Suite 270
Walnut Creek, CA 94598

Shipping Address 3

John Muir Health Infusion Pharmacy
177 La Casa Via
Suite 350
Walnut Creek, CA 94598

Shipping Address 4

Mariner Advanced Pharmacy Corp
345 CONVENTION WAY, STE C
REDWOOD CITY, CA 94063

Shipping Address 5

Universal Compounding Pharmacy
2895 Temple Ave
Signal Hill, CA 90755-2212

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/15/2025	07/01/2025		04/15/2025
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/15/2025	07/01/2025		04/15/2025
Contract Detail	ACCREDO HEALTH GROUP INC	2410 WARDLOW RD	STE 101	CORONA	CA	92878	04/15/2025	07/01/2025		04/15/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/15/2025	07/01/2025		04/15/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/15/2025	07/01/2025		04/15/2025
Contract Detail	BIOLOGICS, INC.	BIOLOGICS BY MCKESSON	11800 WESTON PARKWAY	CARY	NC	27513	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	04/15/2024	07/01/2024		07/01/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/14/2023	10/01/2023		10/01/2023
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/14/2023	10/01/2023		10/01/2023
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	04/15/2024	07/01/2024		07/01/2024
Contract Detail	GARFIELD BEACH CVS, L.L.C.	CVS PHARMACY # 16117	560 CONTRA COSTA BLVD	PLEASANT HILL	CA	94523	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 06526	6490 CLAYTON RD	CLAYTON	CA	94517	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA CVS/PHARMACY # 4326	4028 LONE TREE WAY	ANTIOCH	CA	94531	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09509	4424 TREAT BLVD	CONCORD	CA	94521	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09299	1617 CANYON DR	PINOLE	CA	94564	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09875	230 ATLANTIC AVE	PITTSBURG	CA	94565	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09815	738 BANCROFT RD	WALNUT CREEK	CA	94598	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09827	5408 YGNACIO VALLEY RD	CONCORD	CA	94521	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09253	560 CENTER AVE	MARTINEZ	CA	94553	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09238	2677 CLAYTON RD	CONCORD	CA	94519	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09989	6668 ALHAMBRA AVE	MARTINEZ	CA	94553	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 04283	3171 BALFOUR RD	BRENTWOOD	CA	94513	07/14/2023	10/01/2023		10/01/2023
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09761	2100 COLUMBUS PKWY	BENICIA	CA	94510	07/14/2023	10/01/2023		10/01/2023
Contract Detail	OAK GROVE PHARMACY	785 OAK GROVE RD STE G2		CONCORD	CA	94518-3605	07/01/2024	10/01/2024		10/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/11/2023	04/01/2023		04/01/2023
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/06/2023	04/01/2023		04/01/2023
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	01/11/2023	04/01/2023		04/01/2023
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	01/11/2023	04/01/2023		04/01/2023
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	01/11/2023	04/01/2023		04/01/2023
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/11/2023	04/01/2023		04/01/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/11/2023	04/01/2023		04/01/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/14/2023	10/01/2023		10/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/14/2023	10/01/2023		10/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/14/2023	10/01/2023		10/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/14/2023	10/01/2023		10/01/2023
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/15/2024	07/01/2024		07/01/2024
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/15/2024	07/01/2024		07/01/2024
Contract Detail	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	04/15/2024	07/01/2024		07/01/2024
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/04/2024	07/01/2024		07/01/2024
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/04/2024	07/01/2024		07/01/2024
Contract Detail	WALGREEN CO	DBA: WALGREENS #11614	2750 PINOLE VALLEY RD	PINOLE	CA	94564	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO	DBA: WALGREENS #9102	2271 BALFOUR RD	BRENTWOOD	CA	94513	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO	DBA: WALGREENS #09978	6570 LONE TREE WAY	BRENTWOOD	CA	94513	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15003	1990 MONUMENT BLVD.	CONCORD	CA	94520-3800	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07376	2901 RAILROAD AVE	PITTSBURG	CA	94565-5224	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03171	1050 REDWOOD STREET	VALLEJO	CA	94590	04/18/2023	07/01/2023	02/25/2025	02/25/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15078	2995 YGNACIO VALLEY RD ENCINA GRANDE SHOPPING CENTER	WALNUT CREEK	CA	94598	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13026	2700 WILLOW PASS RD	BAY POINT	CA	94565	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05864	721 GREGORY LANE	PLEASANT HILL	CA	94523-2763	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15296	2262 MARKET ST	SAN FRANCISCO	CA	94114	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04724	3416 DEER VALLEY RD.	ANTIOCH	CA	94531-6650	04/18/2023	07/01/2023	11/08/2024	12/12/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03164	1800 CONCORD AVE	CONCORD	CA	94520	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04026	2900 N MAIN ST	WALNUT CREEK	CA	94597	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06101	3655 ALHAMBRA AVE	MARTINEZ	CA	94553	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04491	15650 SAN PABLO AVE.	SAN PABLO	CA	94806	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06871	4520 BALFOUR RD	BRENTWOOD	CA	94513	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02112	5437 CLAYTON ROAD	CLAYTON	CA	94517	04/18/2023	07/01/2023		07/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050496A	Child	DSH	JOHN MUIR MEDICAL CENTER - CONCORD	JOHN MUIR MED CENTER CONCORD Behring Pavilion - Short Stay Infusion Center	2540 EAST ST	CONCORD	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Change Request		Universal Compounding Pharmacy 2895 Temple Ave Signal Hill, CA 90755-2212	4/21/2025 9:23 AM
Addresses	Shipping Address	Update	Change Request	Mariner Advanced Pharmacy Corp 43 E 3rd Ave San Mateo, CA 94401	Mariner Advanced Pharmacy Corp 345 CONVENTION WAY, STE C REDWOOD CITY, CA 94063	12/4/2024 6:44 AM
Details	Last Recertification Date	Update	Recertification	8/17/2023 11:57:57 AM	8/18/2024 9:51:30 AM	8/18/2024 9:51 AM
Addresses	Shipping Address	Update	Change Request	Infusion Clinic at John Muir Health 177 La Casa Via Suite 300 Walnut Creek, CA 94598	John Muir Health Infusion Pharmacy 177 La Casa Via Suite 350 Walnut Creek, CA 94598	3/4/2024 7:02 AM
Addresses	Shipping Address	Insert	Change Request		Mariner Advanced Pharmacy Corp 43 E 3rd Ave San Mateo, CA 94401	1/26/2024 8:26 AM
Addresses	Shipping Address	Insert	Change Request		JOHN MUIR MEDICAL CENTER - CONCORD 2540 EAST STREET Concord, CA 94520	10/17/2023 7:48 AM
Addresses	Shipping Address	Insert	Change Request		Pavilion Pharmacy at John Muir Health 177 La Casa Via Suite 270 Walnut Creek, CA 94598	10/17/2023 7:48 AM
Addresses	Shipping Address	Insert	Change Request		Infusion Clinic at John Muir Health 177 La Casa Via Suite 300 Walnut Creek, CA 94598	10/17/2023 7:48 AM
Details	Last Recertification Date	Update	Recertification		8/17/2023 11:57:57 AM	8/17/2023 11:57 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1801821376 (CA)		4/14/2023 3:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/14/2023 3:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		HSP40496G	4/14/2023 3:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	4/14/2023 3:03 PM
Contacts	Authorizing Official	Update	Change Request	Pass, Chris Chief Financial Officer John Muir Health 9259412622	Harris, Zach VP Ancillary Services John Muir Health 8084570157	1/26/2023 8:30 AM
Contacts	Primary Contact	Update	Change Request	Iyoya, Martin Ken Executive Director of Pharmacy John Muir Health 9259474410	Dahl, Nikolai Tyler Program Manager - Medication Utilization John Muir Health 9259473243	1/9/2023 7:29 AM
Details	State	Update		Approved	Active	1/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	7/5/2022 12:00:00 AM		12/2/2022 10:48 AM
Dates	Participating Approval Date	Update	Reinstatement	6/13/2022 8:52:50 AM	12/2/2022 10:48:08 AM	12/2/2022 10:48 AM
Details	State	Update	Reinstatement	Terminated	Approved	12/2/2022 10:48 AM
Dates	Registration Date	Update	Reinstatement	4/14/2022 2:55:42 PM	10/3/2022 3:21:10 PM	12/2/2022 10:48 AM
Dates	Signed By Date	Update	Reinstatement	6/3/2022 7:26:26 PM	11/30/2022 7:04:03 PM	12/2/2022 10:48 AM
Dates	Start Date	Update	Reinstatement	7/1/2022 12:00:00 AM	1/1/2023 12:00:00 AM	12/2/2022 10:48 AM
Terminations	Termination Comments	Update	Reinstatement	No medications were purchased under 340B as we never setup the third party aggregator.		12/2/2022 10:48 AM
Terminations	Termination Date	Update	Reinstatement	10/1/2022 12:00:00 AM		12/2/2022 10:48 AM
Terminations	Termination Effective Date	Update	Reinstatement	7/5/2022 12:00:00 AM		12/2/2022 10:48 AM
Terminations	Termination Reason	Update	Reinstatement	Never implemented the 340B Program		12/2/2022 10:48 AM
Details	Comments Public	Insert	Reinstatement		Participated starting 7/1/2022, Terminated 10/1/2022, reinstating on 1/1/2023	12/2/2022 10:41 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/5/2022 12:00:00 AM	7/12/2022 7:09 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/12/2022 7:09 AM
Terminations	Termination Comments	Update	Termination Request		No medications were purchased under 340B as we never setup the third party aggregator.	7/12/2022 7:09 AM
Terminations	Termination Date	Update	Termination Request		10/1/2022 12:00:00 AM	7/12/2022 7:09 AM
Terminations	Termination Effective Date	Update	Termination Request		7/5/2022 12:00:00 AM	7/12/2022 7:09 AM
Terminations	Termination Reason	Update	Termination Request		Never implemented the 340B Program	7/12/2022 7:09 AM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Pass, Chris Chief Financial Officer John Muir Health 9259412622	6/13/2022 8:52 AM
Details	340B ID	Update	New Registration		DSH050496	6/13/2022 8:52 AM
Dates	Participating Approval Date	Update	New Registration		6/13/2022 8:52:50 AM	6/13/2022 8:52 AM
Details	State	Update	New Registration	Pending	Approved	6/13/2022 8:52 AM
Dates	Signed By Date	Update	New Registration		6/3/2022 7:26:26 PM	6/13/2022 8:52 AM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	6/13/2022 8:52 AM
Addresses	Main Address	Insert	New Registration		2540 EAST STREET CONCORD, CA 94520	4/14/2022 2:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2022 2:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1801821376	4/14/2022 2:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/14/2022 2:55 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801821376	4/14/2022 2:55 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/14/2022 2:55 PM
Contacts	Primary Contact	Insert	New Registration		Iyoya, Martin Ken Executive Director of Pharmacy John Muir Health 9259474410	4/14/2022 2:55 PM
Contacts	Authorizing Official	Insert	New Registration		Pass, Chris Chief Financial Officer John Muir Health 9259412622	4/14/2022 2:55 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2022 2:55 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2022 2:55 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2022 2:55 PM
Details	Grant Number	Insert	New Registration			4/14/2022 2:55 PM
Details	340B ID	Insert	New Registration			4/14/2022 2:55 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2022 2:55 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2022 2:55 PM
Details	Medicare Provider Number	Insert	New Registration		050496	4/14/2022 2:55 PM
Details	Entity Name	Insert	New Registration		JOHN MUIR MEDICAL CENTER - CONCORD	4/14/2022 2:55 PM
Details	NOFO Number	Insert	New Registration			4/14/2022 2:55 PM
Details	Program Code	Insert	New Registration		DSH	4/14/2022 2:55 PM
Details	Entity Subname	Insert	New Registration			4/14/2022 2:55 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2022 2:55 PM
Details	State	Insert	New Registration		Pending	4/14/2022 2:55 PM
Dates	Registration Date	Insert	New Registration		4/14/2022 2:55:42 PM	4/14/2022 2:55 PM
Dates	Signed By Date	Insert	New Registration			4/14/2022 2:55 PM
Dates	Start Date	Insert	New Registration			4/14/2022 2:55 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2022 2:55 PM
Terminations	Termination Date	Insert	New Registration			4/14/2022 2:55 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2022 2:55 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2022 2:55 PM