Covered Entity Details

DSH050195F WASHINGTON HOSPITAL HEALTHCARE SYSTEM (Approved) - information as of 4/30/2025 10:54:02 PM

Main Details

Name

WASHINGTON HOSPITAL HEALTHCARE SYSTEM

Subdivision Name

Medical Imaging - Medical Imaging

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050195F

Medicare Provider Number

050195

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/11/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/21/2025

Last Recertification Date

Contacts

Authorizing Official

Washington Hospital Healthcare System
Larry LaBossiere, SVP & COO
(510) 818-6586

Primary Contact

Washington Hospital Healthcare System
Minh-Thu Dennen, Director of Pharmacy
(510) 818-6114

Addresses

Street Address

2500 Mowry Ave
160
Fremont, CA 94538

Billing Address

Washington Hospital HealthCare System
2000 MOWRY AVE
FREMONT, CA 94538

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	050195	1780614685

Shipping Addresses

Shipping Address 1

Washington Hospital HealthCare System
2000 MOWRY AVE
FREMONT, CA 94538

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
DSH050195A	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Infusion Center	2500 Mowry Ave	Fremont	CA	Active
DSH050195B	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Wound Services - Wound Clinic	39141 Civic Center Dr	Fremont	CA	Active
DSH050195C	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Radiation Therapy - Radiation Oncology Center	39101 Civic Center Drive	Fremont	CA	Active
DSH050195D	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Diabetic at Outpatient - Diabetes Program	3575 Beacon Ave	Fremont	CA	Active
DSH050195E	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Lymphedema Therapy - Lymphedema Clinic	2500 Mowry Ave	Fremont	CA	Active
DSH050195F	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Medical Imaging - Medical Imaging	2500 Mowry Ave	Fremont	CA	Approved
DSH050195G	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Outpatient Imaging Center - Outpatient Imaging Center	2500 Mowry Ave	Fremont	CA	Approved
DSH050195H	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Mammography Womens Center - Womens Center	2500 Mowry Ave Suite 150	Fremont	CA	Approved
DSH050195J	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Prenatal Diagnostic Center - Prenatal Diagnostic Clinic	1900 Mowry Ave	Fremont	CA	Approved
DSH050195K	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Interventional Radiology - Interventional Radiology	2500 Mowry Ave	Fremont	CA	Approved
DSH050195L	Child	DSH	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	Bone Density Womens Center - Womens Center	2500 Mowry Ave Suite 150	Fremont	CA	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		LaBossiere, Larry SVP & COO Washington Hospital Healthcare System 5108186586	4/21/2025 12:42 PM
Details	340B ID	Update	New Registration		DSH050195F	4/21/2025 12:42 PM
Details	Entity Name	Update	New Registration	WASHINGTON HOSPITAL DISTRICT	WASHINGTON HOSPITAL HEALTHCARE SYSTEM	4/21/2025 12:42 PM
Details	Entity Subname	Update	New Registration	Medical Imaging	Medical Imaging - Medical Imaging	4/21/2025 12:42 PM
Dates	Participating Approval Date	Update	New Registration		4/21/2025 12:42:09 PM	4/21/2025 12:42 PM
Details	State	Update	New Registration	Pending	Approved	4/21/2025 12:42 PM
Dates	Signed By Date	Update	New Registration		4/15/2025 7:01:14 PM	4/21/2025 12:42 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/21/2025 12:42 PM
Contacts	Authorizing Official	Update	Profile Change Request	LaBossiere, Larry VP & COO Washington Hospital Healthcare System 5108186586	LaBossiere, Larry SVP & COO Washington Hospital Healthcare System 5108186586	4/16/2025 6:40 AM
Addresses	Billing Address	Insert	New Registration		Washington Hospital HealthCare System 2000 MOWRY AVE FREMONT, CA 94538	4/15/2025 7:01 PM
Addresses	Shipping Address	Insert	New Registration		Washington Hospital HealthCare System 2000 MOWRY AVE FREMONT, CA 94538	4/15/2025 7:01 PM
Addresses	Main Address	Insert	New Registration		2500 Mowry Ave 160 Fremont, CA 94538	4/11/2025 5:45 PM
Addresses	Billing Address	Insert	New Registration		Washington Hospital HealthCare System 2000 MOWRY AVE FREMONT, CA 94538	4/11/2025 5:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 5:45 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		050195	4/11/2025 5:45 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/11/2025 5:45 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1780614685	4/11/2025 5:45 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/11/2025 5:45 PM
Contacts	Primary Contact	Insert	New Registration		Dennen, Minh-Thu Director of Pharmacy Washington Hospital Healthcare System 5108186114	4/11/2025 5:45 PM
Contacts	Authorizing Official	Insert	New Registration		LaBossiere, Larry VP & COO Washington Hospital Healthcare System 5108186586	4/11/2025 5:45 PM
Details	Assistance Received From Date	Insert	New Registration			4/11/2025 5:45 PM
Details	Assistance Received To Date	Insert	New Registration			4/11/2025 5:45 PM
Details	Last Recertification Date	Insert	New Registration			4/11/2025 5:45 PM
Details	Grant Number	Insert	New Registration			4/11/2025 5:45 PM
Details	340B ID	Insert	New Registration			4/11/2025 5:45 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2025 5:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2025 5:45 PM
Details	Medicare Provider Number	Insert	New Registration		050195	4/11/2025 5:45 PM
Details	Entity Name	Insert	New Registration		WASHINGTON HOSPITAL DISTRICT	4/11/2025 5:45 PM
Details	NOFO Number	Insert	New Registration			4/11/2025 5:45 PM
Details	Program Code	Insert	New Registration		DSH	4/11/2025 5:45 PM
Details	Entity Subname	Insert	New Registration		Medical Imaging	4/11/2025 5:45 PM
Dates	Participating Approval Date	Insert	New Registration			4/11/2025 5:45 PM
Details	State	Insert	New Registration		Pending	4/11/2025 5:45 PM
Dates	Registration Date	Insert	New Registration		4/11/2025 5:45:36 PM	4/11/2025 5:45 PM
Dates	Signed By Date	Insert	New Registration			4/11/2025 5:45 PM
Dates	Start Date	Insert	New Registration			4/11/2025 5:45 PM
Terminations	Termination Comments	Insert	New Registration			4/11/2025 5:45 PM
Terminations	Termination Date	Insert	New Registration			4/11/2025 5:45 PM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2025 5:45 PM
Terminations	Termination Reason	Insert	New Registration			4/11/2025 5:45 PM