Covered Entity Details

DSH030014AF HONORHEALTH JOHN C. LINCOLN MED CTR (Active) - information as of 6/28/2025 12:21:12 AM

Main Details

Name

HONORHEALTH JOHN C. LINCOLN MED CTR

Subdivision Name

HonorHealth Cancer Care - GynOnc Shea

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH030014AF

Medicare Provider Number

030014

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

6/1/2023

Participating Start Date

6/12/2023

Participating Approval Date

6/9/2023

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

HonorHealth
Lisa Montman, SVP/CFO
(480) 587-5120

Primary Contact

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

Addresses

Street Address

10197 N 92nd St #101
Scottsdale, AZ 85258

Billing Address

HONORHEALTH JOHN C. LINCOLN MED CTR
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
AK	HS757IP,HS757OP,1006416,1753122	1770690695
AL	JOH0014N	1770690695
AR	189215105	1770690695
AZ	022241	1770690695
CA	1386608859,860181654,860181654WV,90367,PRV006826,QMP000004946960,XHSP32340,XHSP42340,1770690695	1770690695
CO	860181654,9000195815,95190112	1770690695
CT	003054129,008047201	1770690695
DC	055575200,60404343,1770690695	1770690695
FL	092474100,1326503,245412000,860117301,ND895,860181654	1770690695
GA	000487946X,003116091A,003176592A,003176648A,860181654,N1425,NR - REVAL,003118615A	1770690695
HI	860181654,1770690695,010156	1770690695
IA	02885297,0983767,1983767,1770690695	1770690695
ID	002925100,1770690695	1770690695
IL	860117301001,860181654,860181654006,N1425,1770690695	1770690695
IN	201035820A,300042446,860181654,1770690695	1770690695
KS	02885297,100100590C,860181654	1770690695
KY	01220136,0122013600,N1098839,N1425,ND895,PDZ000001481293	1770690695
LA	10025901,1749982,60065488,1770690695,3868172	1770690695
MA	0964397,110027159A,110027159B,35974	1770690695
MD	02885297,488644,531209400,70025901,860181654,1770690695	1770690695
ME	191160000,1770690695	1770690695
MI	30-4908703,40-4908712,860117301,860181654,1770690695	1770690695
MN	00500080007,300969,447317500,860181654,1770690695	1770690695
MO	011380201,N1425,1770690695	1770690695
MS	001074063,1770690695	1770690695
NC	9300014,1770690695	1770690695
NE	10026210700,10026374906	1770690695
NJ	02885297,10025901,60159345,1770690695	1770690695
NM	01201026,201080235,24051837,860181654	1770690695
NV	001188961,02885297,1770690695,860181654	1770690695
NY	01619396,111031000122,488644,860181654	1770690695
OH	5187257,6921880,860117301001,860181654,860181654D	1770690695
OK	100704870A	1770690695
OR	128579,860117301,860181654,P00000979846,1770690695	1770690695
PA	1007457650007,1007632800001,30245244,43957,VC9417,1770690695	1770690695
SC	11680A,12148B	1770690695
TN	0012108,0030014,02885297,Q013661	1770690695
TX	02885297,071480001,QMP000005075548,1770690695	1770690695
UT	1023425,QMP000003687930,1770690695	1770690695
VA	860181654,1770690695	1770690695
VT	0030014	1770690695
WA	02885297,1018702,151234,QMP000004937946,1770690695	1770690695
WI	03996805,100056786,100102520,80517700,1770690695	1770690695
WV	860181654,9810047000,1770690695	1770690695
MT	1770690695	1770690695
RI	1770690695	1770690695
WY	1770690695	1770690695
DE		1770690695

Shipping Addresses

Shipping Address 1

HonorHealth Cancer Transplant Institute Pharmacy
10460 N 92nd St #305
Scottsdale, AZ 85258

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
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/11/2025 11:04 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1753122	3/11/2025 11:04 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AK	3/11/2025 11:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1006416	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		AK	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		ME	12/13/2024 12:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/12/2024 2:47 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		010156	12/12/2024 2:47 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		HI	12/12/2024 2:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/10/2024 2:25 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		860181654	9/10/2024 2:25 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NV	9/10/2024 2:25 PM
Addresses	Shipping Address	Delete	Recertification	HonorHealth John C Lincoln Medical Center Pharmacy 10460 N 92nd St #305 Scottsdale, AZ 85258		8/15/2024 12:14 PM
Addresses	Shipping Address	Insert	Recertification		HonorHealth Cancer Transplant Institute Pharmacy 10460 N 92nd St #305 Scottsdale, AZ 85258	8/15/2024 12:14 PM
Details	Last Recertification Date	Update	Recertification	8/22/2023 4:22:43 PM	8/15/2024 12:14:21 PM	8/15/2024 12:14 PM
Details	Entity Subname	Update	Recertification	Virginia G. Piper Cancer Care Center-GynOnc Shea	HonorHealth Cancer Care - GynOnc Shea	8/15/2024 12:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/12/2024 12:14 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		PDZ000001481293	6/12/2024 12:14 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KY	6/12/2024 12:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/12/2024 12:14 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		10026374906	6/12/2024 12:14 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NE	6/12/2024 12:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		003118615A	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		GA	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		3868172	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		LA	3/12/2024 11:04 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	01074063 (MS)		12/13/2023 11:59 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CA	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		DC	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		HI	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IA	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		ID	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IL	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		IN	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		LA	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MD	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MI	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MN	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MO	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MS	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		MT	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NC	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NJ	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NV	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OR	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		RI	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		TX	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		UT	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		VA	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WA	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WI	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1770690695	9/14/2023 7:35 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WY	9/14/2023 7:35 PM
Contacts	Authorizing Official	Update	Profile Change Request	Replogle, Lisa SVP/CFO HonorHealth 4805875120	Montman, Lisa SVP/CFO HonorHealth 4805875120	9/5/2023 12:01 PM
Details	Last Recertification Date	Update	Recertification		8/22/2023 4:22:43 PM	8/22/2023 4:22 PM
Details	Entity Subname	Update	Recertification	Virginia G. Piper Cancer Care Center-GynOnc Shea - Virginia G. Piper Cancer Care Center-GynOnc Shea	Virginia G. Piper Cancer Care Center-GynOnc Shea	8/22/2023 4:22 PM
Contacts	Authorizing Official	Update	AO Change Request	mansukhani, lalit COO HonorHealth Thompson Peak Medical Center 4803247001	Replogle, Lisa SVP/CFO HonorHealth 4805875120	8/10/2023 5:31 PM
Details	State	Update	OPA Edit	Approved	Active	6/12/2023 10:49 AM
Dates	Start Date	Update	OPA Edit	7/1/2023 12:00:00 AM	6/12/2023 12:00:00 AM	6/12/2023 10:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/10/2023 1:32 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		860181654	6/10/2023 1:32 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	6/10/2023 1:32 AM
Addresses	Shipping Address	Update	New Registration	HonorHealth dba HonorHealth John C Lincoln Medical Center 10460 N 92nd St #305 Scottsdale, AZ 85258	HonorHealth John C Lincoln Medical Center Pharmacy 10460 N 92nd St #305 Scottsdale, AZ 85258	6/9/2023 10:58 AM
Addresses	Main Address	Insert	New Registration		10197 N 92nd St #101 Scottsdale, AZ 85258	6/9/2023 10:58 AM
Addresses	Billing Address	Insert	New Registration		HONORHEALTH JOHN C. LINCOLN MED CTR PO Box 14890 Scottsdale, AZ 85267	6/9/2023 10:58 AM
Contacts	Signed By	Insert	New Registration		mansukhani, lalit COO HonorHealth Thompson Peak Medical Center 4803247001	6/9/2023 10:58 AM
Details	340B ID	Update	New Registration		DSH030014AF	6/9/2023 10:58 AM
Details	Entity Subname	Update	New Registration	Virginia G. Piper Cancer Care Center-GynOnc Shea	Virginia G. Piper Cancer Care Center-GynOnc Shea - Virginia G. Piper Cancer Care Center-GynOnc Shea	6/9/2023 10:58 AM
Dates	Participating Approval Date	Update	New Registration		6/9/2023 10:58:09 AM	6/9/2023 10:58 AM
Details	State	Update	New Registration	Pending	Approved	6/9/2023 10:58 AM
Dates	Signed By Date	Update	New Registration		6/9/2023 1:40:14 AM	6/9/2023 10:58 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	6/9/2023 10:58 AM
Addresses	Main Address	Insert	New Registration		10197 N 92nd St #101 Scottsdale, AZ 85258	6/1/2023 8:19 PM
Addresses	Billing Address	Insert	New Registration		HONORHEALTH JOHN C. LINCOLN MED CTR PO Box 14890 Scottsdale, AZ 85267	6/1/2023 8:19 PM
Addresses	Shipping Address	Insert	New Registration		HonorHealth dba HonorHealth John C Lincoln Medical Center 10460 N 92nd St #305 Scottsdale, AZ 85258	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HS757IP	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HS757OP	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		JOH0014N	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		189215105	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		022241	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AZ	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1386608859	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654WV	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		90367	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		PRV006826	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		QMP000004946960	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		XHSP32340	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		XHSP42340	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9000195815	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		95190112	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CO	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003054129	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		008047201	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		055575200	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		DC	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		60404343	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		DC	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		092474100	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1326503	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		245412000	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ND895	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000487946X	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003116091A	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003176592A	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		003176648A	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1425	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		NR - REVAL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		HI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0983767	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1983767	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		002925100	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ID	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301001	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654006	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1425	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		201035820A	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		300042446	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100100590C	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01220136	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0122013600	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1098839	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1425	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ND895	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10025901	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1749982	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		60065488	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0964397	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110027159A	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110027159B	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		35974	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		488644	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		531209400	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		70025901	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		191160000	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30-4908703	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		40-4908712	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00500080007	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		300969	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		447317500	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		011380201	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		N1425	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		001074063	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01074063	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9300014	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10026210700	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NE	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10025901	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		60159345	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01201026	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		201080235	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		24051837	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NM	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		001188961	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NV	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01619396	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		111031000122	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		488644	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		5187257	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		6921880	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301001	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654D	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100704870A	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		128579	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860117301	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		P00000979846	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007457650007	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007632800001	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		30245244	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		43957	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		VC9417	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11680A	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		12148B	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0012108	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0030014	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		Q013661	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		071480001	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		QMP000005075548	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1023425	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		QMP000003687930	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		UT	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0030014	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VT	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		02885297	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1018702	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		151234	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		QMP000004937946	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		03996805	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100056786	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100102520	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		80517700	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		860181654	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		9810047000	6/1/2023 8:19 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		AZ	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		CO	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		DC	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		DE	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		HI	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		KS	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		ME	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MN	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		MT	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NE	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NM	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NV	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		RI	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		SC	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		UT	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		VT	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		WV	6/1/2023 8:19 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770690695	6/1/2023 8:19 PM
Medicaid Billing	NPI: State	Insert	New Registration		WY	6/1/2023 8:19 PM
Contacts	Primary Contact	Insert	New Registration		Lindgren, Kristjon 340B Program Director HonorHealth 6027935509	6/1/2023 8:19 PM
Contacts	Authorizing Official	Insert	New Registration		mansukhani, lalit COO HonorHealth Thompson Peak Medical Center 4803247001	6/1/2023 8:19 PM
Details	Assistance Received From Date	Insert	New Registration			6/1/2023 8:19 PM
Details	Assistance Received To Date	Insert	New Registration			6/1/2023 8:19 PM
Details	Last Recertification Date	Insert	New Registration			6/1/2023 8:19 PM
Details	Grant Number	Insert	New Registration			6/1/2023 8:19 PM
Details	340B ID	Insert	New Registration			6/1/2023 8:19 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			6/1/2023 8:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			6/1/2023 8:19 PM
Details	Medicare Provider Number	Insert	New Registration		030014	6/1/2023 8:19 PM
Details	Entity Name	Insert	New Registration		HONORHEALTH JOHN C. LINCOLN MED CTR	6/1/2023 8:19 PM
Details	NOFO Number	Insert	New Registration			6/1/2023 8:19 PM
Details	Program Code	Insert	New Registration		DSH	6/1/2023 8:19 PM
Details	Entity Subname	Insert	New Registration		Virginia G. Piper Cancer Care Center-GynOnc Shea	6/1/2023 8:19 PM
Dates	Participating Approval Date	Insert	New Registration			6/1/2023 8:19 PM
Details	State	Insert	New Registration		Pending	6/1/2023 8:19 PM
Dates	Registration Date	Insert	New Registration		6/1/2023 8:19:36 PM	6/1/2023 8:19 PM
Dates	Signed By Date	Insert	New Registration			6/1/2023 8:19 PM
Dates	Start Date	Insert	New Registration			6/1/2023 8:19 PM
Terminations	Termination Comments	Insert	New Registration			6/1/2023 8:19 PM
Terminations	Termination Date	Insert	New Registration			6/1/2023 8:19 PM
Terminations	Termination Effective Date	Insert	New Registration			6/1/2023 8:19 PM
Terminations	Termination Reason	Insert	New Registration			6/1/2023 8:19 PM