Covered Entity Details

DSH050174V ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital (Active) - information as of 4/25/2025 6:36:33 PM

Main Details

Name

ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital

Subdivision Name

Santa Rosa Memorial Hospital - Pharmacotherapy

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050174V

Medicare Provider Number

050174

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2025

Participating Start Date

4/1/2025

Participating Approval Date

2/3/2025

Last Recertification Date

Contacts

Authorizing Official

Providence St Joseph Health
Erika Wright, CFO
(707) 525-5300

Primary Contact

Providence
Jesse Peterson, 340B Program Director, South Division
(651) 324-2207

Addresses

Street Address

3555 Round Barn Circle
100
Santa Rosa, CA 95403

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA		1134152549

Shipping Addresses

Same as Street Address

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
DSH050174A	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SANTA ROSA MEMORIAL AMBULATORY SURG	525 DOYLE PARK DR	SANTA ROSA	CA	Active
DSH050174B	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SRMH - Diagnostic Radiology	121 Sotoyome	Santa Rosa	CA	Active
DSH050174C	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SRMH - Outpatient Behavioral Health Services	405 W. College Avenue	Santa Rosa	CA	Active
DSH050174D	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	St. Joseph Health - Outpatient Cancer Center Fountain Grove	3555 Round Barn Circle	Santa Rosa	CA	Active
DSH050174E	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	St. Joseph Health - Outpatient Cancer Center Lynch Creek	110 Lynch Creek Way	Petaluma	CA	Active
DSH050174F	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	URGENT CARE CENTER ROHNERT PARK	1450 MEDICAL CENTER DR	ROHNERT PARK	CA	Terminated
DSH050174G	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	URGENT CARE-SANTA ROSA	925 CORPORATE CNTR PKWY A	SANTA ROSA	CA	Active
DSH050174H	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	ST JOSEPH URGENT CARE WINDSOR	6580 HEMBREE LN 270	WINDSOR	CA	Active
DSH050174J	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SRMH - Wound Care Clinic / Wound Care Clinic	500 Doyle Park Drive	Santa Rosa	CA	Active
DSH050174K	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SRMH - Physical Therapy Services (Rehabilitation Services)	1170 Montgomery Drive	Santa Rosa	CA	Terminated
DSH050174L	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SRMH - Sonoma County Physical Therapy (Rehabilitation Services)	1255 North Dutton Avenue	Santa Rosa	CA	Terminated
DSH050174M	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SRMH - Sweet Success Clinic / Diabetes Clinic	500 Doyle Park Drive	Santa Rosa	CA	Terminated
DSH050174N	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SRMH - Non-Invasive Cardiology / Non-Invasive Cardiology	500 Doyle Park Drive	Santa Rosa	CA	Terminated
DSH050174P	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	Advanced Surgery Institute	1739 4th Street	Santa Rosa	CA	Terminated
DSH050174Q	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SANTA ROSA MEMORIAL HOSPITAL - Endoscopy	525 DOYLE PARK DR	SANTA ROSA	CA	Active
DSH050174R	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SANTA ROSA MEMORIAL HOSPITAL - Magnetic Resonance Imaging (MRI)	121 SOTOYOME ST	SANTA ROSA	CA	Active
DSH050174S	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SANTA ROSA MEMORIAL HOSPITAL - Nuclear Medicine	121 SOTOYOME ST	SANTA ROSA	CA	Active
DSH050174T	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	SANTA ROSA MEMORIAL HOSPITAL - Computed Tomography (CT) Scan	121 SOTOYOME ST	SANTA ROSA	CA	Active
DSH050174U	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	Sleep Lab - Sleep Lab	585 W College Ave	Santa Rosa	CA	Active
DSH050174V	Child	DSH	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	Santa Rosa Memorial Hospital - Pharmacotherapy	3555 Round Barn Circle	Santa Rosa	CA	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		Wright, Erika CFO Providence St Joseph Health 7075255300	2/3/2025 8:19 AM
Details	340B ID	Update	New Registration		DSH050174V	2/3/2025 8:19 AM
Details	Entity Name	Update	New Registration	SANTA ROSA MEMORIAL HOSPITAL	ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital	2/3/2025 8:19 AM
Details	Entity Subname	Update	New Registration	Santa Rosa Memorial Hospital	Santa Rosa Memorial Hospital - Pharmacotherapy	2/3/2025 8:19 AM
Dates	Participating Approval Date	Update	New Registration		2/3/2025 8:19:23 AM	2/3/2025 8:19 AM
Details	State	Update	New Registration	Pending	Approved	2/3/2025 8:19 AM
Dates	Signed By Date	Update	New Registration		1/31/2025 6:32:55 PM	2/3/2025 8:19 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	2/3/2025 8:19 AM
Addresses	Main Address	Insert	New Registration		3555 Round Barn Circle 100 Santa Rosa, CA 95403	1/15/2025 11:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1134152549	1/15/2025 11:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		CA	1/15/2025 11:25 AM
Contacts	Authorizing Official	Insert	New Registration		Wright, Erika CFO Providence St Joseph Health 7075255300	1/15/2025 11:25 AM
Contacts	Primary Contact	Insert	New Registration		Peterson, Jesse 340B Program Director, South Division Providence 6513242207	1/15/2025 11:25 AM
Details	Assistance Received From Date	Insert	New Registration			1/15/2025 11:25 AM
Details	Assistance Received To Date	Insert	New Registration			1/15/2025 11:25 AM
Details	Last Recertification Date	Insert	New Registration			1/15/2025 11:25 AM
Details	Grant Number	Insert	New Registration			1/15/2025 11:25 AM
Details	340B ID	Insert	New Registration			1/15/2025 11:25 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2025 11:25 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2025 11:25 AM
Details	Medicare Provider Number	Insert	New Registration		050174	1/15/2025 11:25 AM
Details	Entity Name	Insert	New Registration		SANTA ROSA MEMORIAL HOSPITAL	1/15/2025 11:25 AM
Details	NOFO Number	Insert	New Registration			1/15/2025 11:25 AM
Details	Program Code	Insert	New Registration		DSH	1/15/2025 11:25 AM
Details	Entity Subname	Insert	New Registration		Santa Rosa Memorial Hospital	1/15/2025 11:25 AM
Dates	Participating Approval Date	Insert	New Registration			1/15/2025 11:25 AM
Details	State	Insert	New Registration		Pending	1/15/2025 11:25 AM
Dates	Registration Date	Insert	New Registration		1/15/2025 11:25:41 AM	1/15/2025 11:25 AM
Dates	Signed By Date	Insert	New Registration			1/15/2025 11:25 AM
Dates	Start Date	Insert	New Registration			1/15/2025 11:25 AM
Terminations	Termination Comments	Insert	New Registration			1/15/2025 11:25 AM
Terminations	Termination Date	Insert	New Registration			1/15/2025 11:25 AM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2025 11:25 AM
Terminations	Termination Reason	Insert	New Registration			1/15/2025 11:25 AM