Covered Entity Details

DSH500014W PROVIDENCE HEALTH & SERVICES - WASHINGTON (Active) - information as of 6/15/2025 6:08:28 AM

Main Details

Name

PROVIDENCE HEALTH & SERVICES - WASHINGTON

Subdivision Name

PROVIDENCE HEALTH & SERVICES-WA - Nuclear Medicine - 1401.765000.12439

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500014W

Medicare Provider Number

500014

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/7/2025

Participating Start Date

4/1/2025

Participating Approval Date

3/10/2025

Last Recertification Date

Contacts

Authorizing Official

Providence Health & Services Washington
Scott Combs, CFO
(425) 261-4044

Primary Contact

Providence Health & Services Washington
Eric Werttemberger, Director of Pharmacy
(425) 261-3530

Addresses

Street Address

1717 13TH ST
STE 100
EVERETT, WA 98201-1621

Billing Address

Providence Saint Joseph Health
PO Box 31263
Salt Lake City, UT 84131

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
WA		1700037801
CA		1700037801
OR		1700037801
ID		1700037801
AK		1700037801

Shipping Addresses

Shipping Address 1

Providence Regional Medical Center Everett
1321 Colby Avenue
Everett, WA 98201

Shipping Address 2

Providence Nuclear Medicine Department
1717 13th St
Everett, WA 98201

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
DSH500014A	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROVIDENCE REGIONAL MEDICAL CENTER EVERETT PACIFIC CAMPUS	916 PACIFIC AVENUE	EVERETT	WA	Terminated
DSH500014D	Child	DSH	PROV REGL MED CENTER EVERETT	WOUND CLINIC	1330 ROCKEFELLER AVE	EVERETT	WA	Terminated
DSH500014E	Child	DSH	PROV REGL MED CENTER EVERETT	INTERVENTION CENTER	1509 CALIFORNIA ST	EVERETT	WA	Terminated
DSH500014F	Child	DSH	PROV REGL MED CENTER EVERETT	Breast Center	900 Pacific Avenue, Suite 120	Everett	WA	Terminated
DSH500014G	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Family Maternity Center / Labor and Delivery	900 Pacific Avenue	Everett	WA	Terminated
DSH500014H	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Anesthesia	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014J	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Recovery Room	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014K	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Operating Room	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014L	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Outpatient Therapy Services / Physical Therapy	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014M	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Chemical Dependency	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014N	Child	DSH	PROV REGL MED CENTER EVERETT	Pacific Campus / Maternal Fetal Medicine Clinic	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014P	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Pacific Campus / Post Partum and Post Operative	916 PACIFIC AVE	EVERETT	WA	Terminated
DSH500014Q	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Radiation Oncology	1717 13th Street, Suite #2	Everett	WA	Active
DSH500014R	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PACIFIC CAMPUS / 2 NORTH MED SURG - 2 NORTH MED SURG - OUTPATIENT OBSERVATION BEDS	916 PACIFIC	EVERETT	WA	Terminated
DSH500014S	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	Providence Regional Medical Center Everett Colby Campus - Anticoagulation Clinic	1330 Rockefeller Ave	Everett	WA	Active
DSH500014T	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROV REGIONAL MED CTR EVERETT - Anticoagulation 1401.500040.12335	11603 STATE AVE G	MARYSVILLE	WA	Active
DSH500014U	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROV REGIONAL MED CTR EVERETT - Anticoagulation 1401.500040.12346	12800 BOTHELL EVERETT HWY	EVERETT	WA	Active
DSH500014V	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROV REGIONAL MED CTR EVERETT - Anticoagulation 1401.500040.12349	19200 N KELSEY ST	MONROE	WA	Active
DSH500014W	Child	DSH	PROVIDENCE HEALTH & SERVICES - WASHINGTON	PROVIDENCE HEALTH & SERVICES-WA - Nuclear Medicine - 1401.765000.12439	1717 13TH ST	EVERETT	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Combs, Scott CFO Providence Health & Services Washington 4252614044	3/10/2025 10:36 AM
Details	340B ID	Update	New Registration		DSH500014W	3/10/2025 10:36 AM
Details	Entity Name	Update	New Registration	PROV REGL MED CENTER EVERETT	PROVIDENCE HEALTH & SERVICES - WASHINGTON	3/10/2025 10:36 AM
Details	Entity Subname	Update	New Registration	PROVIDENCE HEALTH & SERVICES-WA	PROVIDENCE HEALTH & SERVICES-WA - Nuclear Medicine - 1401.765000.12439	3/10/2025 10:36 AM
Dates	Participating Approval Date	Update	New Registration		3/10/2025 10:36:40 AM	3/10/2025 10:36 AM
Details	State	Update	New Registration	Pending	Approved	3/10/2025 10:36 AM
Dates	Signed By Date	Update	New Registration		1/10/2025 12:14:45 PM	3/10/2025 10:36 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	3/10/2025 10:36 AM
Contacts	Primary Contact	Update	Profile Change Request	Werttemberger, Eric Director of Pharmacy Providence Health & Services Washington 4252613534	Werttemberger, Eric Director of Pharmacy Providence Health & Services Washington 4252613530	1/7/2025 3:53 PM
Addresses	Main Address	Insert	New Registration		1717 13TH ST STE 100 EVERETT, WA 98201-1621	1/7/2025 3:53 PM
Addresses	Billing Address	Insert	New Registration		Providence Saint Joseph Health PO Box 31263 Salt Lake City, UT 84131	1/7/2025 3:53 PM
Addresses	Shipping Address	Insert	New Registration		Providence Regional Medical Center Everett 1321 Colby Avenue Everett, WA 98201	1/7/2025 3:53 PM
Addresses	Shipping Address	Insert	New Registration		Providence Nuclear Medicine Department 1717 13th St Everett, WA 98201	1/7/2025 3:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700037801	1/7/2025 3:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	1/7/2025 3:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700037801	1/7/2025 3:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	1/7/2025 3:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700037801	1/7/2025 3:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	1/7/2025 3:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700037801	1/7/2025 3:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		ID	1/7/2025 3:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700037801	1/7/2025 3:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	1/7/2025 3:53 PM
Contacts	Primary Contact	Insert	New Registration		Werttemberger, Eric Director of Pharmacy Providence Health & Services Washington 4252613534	1/7/2025 3:53 PM
Contacts	Authorizing Official	Insert	New Registration		Combs, Scott CFO Providence Health & Services Washington 4252614044	1/7/2025 3:53 PM
Details	Assistance Received From Date	Insert	New Registration			1/7/2025 3:53 PM
Details	Assistance Received To Date	Insert	New Registration			1/7/2025 3:53 PM
Details	Last Recertification Date	Insert	New Registration			1/7/2025 3:53 PM
Details	Grant Number	Insert	New Registration			1/7/2025 3:53 PM
Details	340B ID	Insert	New Registration			1/7/2025 3:53 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/7/2025 3:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/7/2025 3:53 PM
Details	Medicare Provider Number	Insert	New Registration		500014	1/7/2025 3:53 PM
Details	Entity Name	Insert	New Registration		PROV REGL MED CENTER EVERETT	1/7/2025 3:53 PM
Details	NOFO Number	Insert	New Registration			1/7/2025 3:53 PM
Details	Program Code	Insert	New Registration		DSH	1/7/2025 3:53 PM
Details	Entity Subname	Insert	New Registration		PROVIDENCE HEALTH & SERVICES-WA	1/7/2025 3:53 PM
Dates	Participating Approval Date	Insert	New Registration			1/7/2025 3:53 PM
Details	State	Insert	New Registration		Pending	1/7/2025 3:53 PM
Dates	Registration Date	Insert	New Registration		1/7/2025 3:53:25 PM	1/7/2025 3:53 PM
Dates	Signed By Date	Insert	New Registration			1/7/2025 3:53 PM
Dates	Start Date	Insert	New Registration			1/7/2025 3:53 PM
Terminations	Termination Comments	Insert	New Registration			1/7/2025 3:53 PM
Terminations	Termination Date	Insert	New Registration			1/7/2025 3:53 PM
Terminations	Termination Effective Date	Insert	New Registration			1/7/2025 3:53 PM
Terminations	Termination Reason	Insert	New Registration			1/7/2025 3:53 PM