Covered Entity Details

DSH380050AB Sky Lakes Medical Center (Approved) - information as of 5/9/2025 10:43:52 PM

Main Details

Name

Sky Lakes Medical Center

Subdivision Name

SKY LAKES GENERAL SURGERY D - SKY LAKES GENERAL SURGERY D

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH380050AB

Medicare Provider Number

380050

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/14/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/5/2025

Last Recertification Date

Contacts

Authorizing Official

Sky Lakes Medical Center
Richard E. Rico, Vice President/CFO
(541) 274-6150

Primary Contact

Sky Lakes Medical Center
Mychal Amos, Director of Pharmacy Services
(541) 274-3799

Addresses

Street Address

2821 DAGGETT AVENUE
Suite 303
KLAMATH FALLS, OR 97601

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
OR	152371	1659340370

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
DSH380050A	Child	DSH	Sky Lakes Medical Center	SKY LAKES PRIMARY CARE CLINIC	2821 Daggett Avenue	KLAMATH FALLS	OR	Active
DSH380050AA	Child	DSH	Sky Lakes Medical Center	SKY LAKES WELLNESS CENTER - SKY LAKES WELLNESS CENTER	128 SOUTH 11TH STREET	KLAMATH FALLS	OR	Approved
DSH380050AB	Child	DSH	Sky Lakes Medical Center	SKY LAKES GENERAL SURGERY D - SKY LAKES GENERAL SURGERY D	2821 DAGGETT AVENUE	KLAMATH FALLS	OR	Approved
DSH380050B	Child	DSH	Sky Lakes Medical Center	SKY LAKES GENERAL SURGERY - A	2301 CLAIRMONT DR	KLAMATH FALLS	OR	Active
DSH380050C	Child	DSH	Sky Lakes Medical Center	SKY LAKES RHEUMATOLOGY	2200 BRYANT WILLIAMS DR	KLAMATH FALLS	OR	Active
DSH380050D	Child	DSH	Sky Lakes Medical Center	CASCADES EAST FAMILY MEDICINE CENTER	2821 DAGGETT AVE	KLAMATH FALLS	OR	Active
DSH380050E	Child	DSH	Sky Lakes Medical Center	SKY LAKES CASCADE EAR, NOSE, THROAT	3000 BRYANT WILLIAMS DR 200	KLAMATH FALLS	OR	Terminated
DSH380050F	Child	DSH	Sky Lakes Medical Center	SKY LAKES KLAMATH MEDICAL CLINIC	2821 Daggett Avenue	Klamath Falls	OR	Terminated
DSH380050G	Child	DSH	Sky Lakes Medical Center	SKY LAKES CANCER TREATMENT CENTER	2610 UHRMANN ROAD	KLAMATH FALLS	OR	Active
DSH380050H	Child	DSH	Sky Lakes Medical Center	SKY LAKES UROLOGY	2630 CAMPUS DR	KLAMATH FALLS	OR	Terminated
DSH380050J	Child	DSH	Sky Lakes Medical Center	SKY LAKES WOMENS HEALTH CLINIC	2801 DAGGETT AVENUE	KLAMATH FALLS	OR	Active
DSH380050K	Child	DSH	Sky Lakes Medical Center	SKY LAKES GASTROENTEROLOGY	2303 CLAIRMONT DR	KLAMATH FALLS	OR	Terminated
DSH380050L	Child	DSH	Sky Lakes Medical Center	SKY LAKES PULMONOLOGY CLINIC	2617 ALMOND STREET	KLAMATH FALLS	OR	Active
DSH380050M	Child	DSH	Sky Lakes Medical Center	SKY LAKES DERMATOLOGY CLINIC	3000 BRYANT WILLIAMS DRIVE	KLAMATH FALLS	OR	Active
DSH380050N	Child	DSH	Sky Lakes Medical Center	SKY LAKES EAR, NOSE AND THROAT CLINIC	3000 Bryant Williams Drive	KLAMATH FALLS	OR	Active
DSH380050P	Child	DSH	Sky Lakes Medical Center	Sky Lakes Primary Care on Almond	2617 Almond Avenue	Klamath Falls	OR	Terminated
DSH380050Q	Child	DSH	Sky Lakes Medical Center	SKY LAKES CEFM ADMIN	2801 Daggett Avenue	KLAMATH FALLS	OR	Active
DSH380050R	Child	DSH	Sky Lakes Medical Center	SOUTH CASCADE SURGERY CENTER	2200 BRYANT WILLIAMS DR	KLAMATH FALLS	OR	Active
DSH380050S	Child	DSH	Sky Lakes Medical Center	SKY LAKES KLAMATH HEART CLINIC	3001 Daggett Avenue	Klamath Falls	OR	Active
DSH380050T	Child	DSH	SKY LAKES MEDICAL CENTER	Primary Care Clinic on Almond	2617 Almond Street	Klamath Falls	OR	Terminated
DSH380050U	Child	DSH	Sky Lakes Medical Center	SKY LAKES GENERAL SURGERY - C	2600 Clover Street	Klamath Falls	OR	Active
DSH380050V	Child	DSH	Sky Lakes Medical Center	SKY LAKES GENERAL SURGERY - B	3000 Bryant Williams Drive	Klamath Falls	OR	Active
DSH380050W	Child	DSH	Sky Lakes Medical Center	SKY LAKES UROLOGY - B	2200 BRYANT WILLIAMS DRIVE	KLAMATH FALLS	OR	Active
DSH380050X	Child	DSH	Sky Lakes Medical Center	SKY LAKES ORTHO - ORTHO	2200 BRYANT WILLIAMS DRIVE	KLAMATH FALLS	OR	Terminated
DSH380050Y	Child	DSH	Sky Lakes Medical Center	SKY LAKES NEUROLOGY CLINIC - NEUROLOGY	3000 BRYANT WILLIAMS DRIVE	KLAMATH FALLS	OR	Active
DSH380050Z	Child	DSH	Sky Lakes Medical Center	SKY LAKES BEHAVIORAL HEALTH CLINIC - BEHAVIORAL HEALTH	2301 MOUNTAIN VIEW BOULEVARD	KLAMATH FALLS	OR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Rico, Richard E. Vice President/CFO Sky Lakes Medical Center 5412746150	5/5/2025 7:42 AM
Details	340B ID	Update	New Registration		DSH380050AB	5/5/2025 7:42 AM
Details	Entity Name	Update	New Registration	SKY LAKES MEDICAL CENTER	Sky Lakes Medical Center	5/5/2025 7:42 AM
Details	Entity Subname	Update	New Registration	SKY LAKES GENERAL SURGERY D	SKY LAKES GENERAL SURGERY D - SKY LAKES GENERAL SURGERY D	5/5/2025 7:42 AM
Dates	Participating Approval Date	Update	New Registration		5/5/2025 7:42:32 AM	5/5/2025 7:42 AM
Details	State	Update	New Registration	Pending	Approved	5/5/2025 7:42 AM
Dates	Signed By Date	Update	New Registration		4/14/2025 4:40:23 PM	5/5/2025 7:42 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/5/2025 7:42 AM
Addresses	Main Address	Insert	New Registration		2821 DAGGETT AVENUE Suite 303 KLAMATH FALLS, OR 97601	4/14/2025 3:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/14/2025 3:21 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		152371	4/14/2025 3:21 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OR	4/14/2025 3:21 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1659340370	4/14/2025 3:21 PM
Medicaid Billing	NPI: State	Insert	New Registration		OR	4/14/2025 3:21 PM
Contacts	Primary Contact	Insert	New Registration		Amos, Mychal Director of Pharmacy Services Sky Lakes Medical Center 5412743799	4/14/2025 3:21 PM
Contacts	Authorizing Official	Insert	New Registration		Rico, Richard E. Vice President/CFO Sky Lakes Medical Center 5412746150	4/14/2025 3:21 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2025 3:21 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2025 3:21 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2025 3:21 PM
Details	Grant Number	Insert	New Registration			4/14/2025 3:21 PM
Details	340B ID	Insert	New Registration			4/14/2025 3:21 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2025 3:21 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2025 3:21 PM
Details	Medicare Provider Number	Insert	New Registration		380050	4/14/2025 3:21 PM
Details	Entity Name	Insert	New Registration		SKY LAKES MEDICAL CENTER	4/14/2025 3:21 PM
Details	NOFO Number	Insert	New Registration			4/14/2025 3:21 PM
Details	Program Code	Insert	New Registration		DSH	4/14/2025 3:21 PM
Details	Entity Subname	Insert	New Registration		SKY LAKES GENERAL SURGERY D	4/14/2025 3:21 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2025 3:21 PM
Details	State	Insert	New Registration		Pending	4/14/2025 3:21 PM
Dates	Registration Date	Insert	New Registration		4/14/2025 3:21:05 PM	4/14/2025 3:21 PM
Dates	Signed By Date	Insert	New Registration			4/14/2025 3:21 PM
Dates	Start Date	Insert	New Registration			4/14/2025 3:21 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2025 3:21 PM
Terminations	Termination Date	Insert	New Registration			4/14/2025 3:21 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2025 3:21 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2025 3:21 PM