| Details | State | Update | | To Be Terminated | Terminated | 7/1/2024 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | | 7/1/2024 12:00:00 AM | 4/30/2024 7:36 AM |
| Details | State | Update | Hospital Type Change Request | Active | To Be Terminated | 4/30/2024 7:36 AM |
| Terminations | Termination Date | Update | Hospital Type Change Request | | 7/1/2024 12:00:00 AM | 4/30/2024 7:36 AM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | | 7/1/2024 12:00:00 AM | 4/30/2024 7:36 AM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | | Change of covered entity type | 4/30/2024 7:36 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/30/2023 8:15:45 AM | 8/30/2023 8:15 AM |
| Details | State | Update | | Approved | Active | 10/1/2022 12:01 AM |
| Addresses | Billing Address | Insert | Hospital Type Change Request | | PROVIDENCE ACCOUNTS PAYABLE
P.O. BOX 696430
SAN ANTONIO, TX 78269-0000 | 8/31/2022 9:28 AM |
| Medicaid Billing | NPI: Number | Delete | Hospital Type Change Request | 1386895886 ( ) | | 8/31/2022 9:28 AM |
| Medicaid Billing | NPI: Number | Insert | Hospital Type Change Request | | 1386895886 | 8/31/2022 9:28 AM |
| Medicaid Billing | NPI: State | Insert | Hospital Type Change Request | | WA | 8/31/2022 9:28 AM |
| Medicaid Billing | NPI: Number | Insert | Hospital Type Change Request | | 1386895886 | 8/31/2022 9:28 AM |
| Medicaid Billing | NPI: State | Insert | Hospital Type Change Request | | OR | 8/31/2022 9:28 AM |
| Contacts | Authorizing Official | Update | Hospital Type Change Request | Blackburn, Susan
CHIEF EXECUTIVE
Providence St Mary Medical Center
5098972290 | Harris, Spencer Dwayne
CFO
Kadlec Regional Medical Center
5099422708 | 8/31/2022 9:28 AM |
| Contacts | Signed By | Insert | Hospital Type Change Request | | Harris, Spencer Dwayne
CFO
Kadlec Regional Medical Center
5099422708 | 8/31/2022 9:28 AM |
| Details | Last Recertification Date | Update | Hospital Type Change Request | 9/15/2019 2:24:47 PM | | 8/31/2022 9:28 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | 7/1/2020 12:00:00 AM | | 8/31/2022 9:28 AM |
| Details | Entity Name | Update | Hospital Type Change Request | Providence Health & Services-Washington | PROV ST MARY MEDICAL CENTER | 8/31/2022 9:28 AM |
| Dates | Participating Approval Date | Update | Hospital Type Change Request | 2/28/2006 12:00:00 AM | 8/31/2022 9:28:26 AM | 8/31/2022 9:28 AM |
| Details | State | Update | Hospital Type Change Request | Terminated | Approved | 8/31/2022 9:28 AM |
| Dates | Registration Date | Update | Hospital Type Change Request | 2/27/2006 12:00:00 AM | 7/5/2022 2:30:52 PM | 8/31/2022 9:28 AM |
| Dates | Signed By Date | Update | Hospital Type Change Request | 2/7/2006 12:00:00 AM | 8/25/2022 12:54:56 PM | 8/31/2022 9:28 AM |
| Dates | Start Date | Update | Hospital Type Change Request | 10/1/2016 12:00:00 AM | 10/1/2022 12:00:00 AM | 8/31/2022 9:28 AM |
| Terminations | Termination Comments | Update | Hospital Type Change Request | Our DSH percentage has been trending down the past couple of years. We plan to reinstate as an RRC on July 1st to prevent a gap in the 340B program in the event our DSH percentage drops below 11.75 | | 8/31/2022 9:28 AM |
| Terminations | Termination Date | Update | Hospital Type Change Request | 7/1/2020 12:00:00 AM | | 8/31/2022 9:28 AM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | 7/1/2020 12:00:00 AM | | 8/31/2022 9:28 AM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | DSH percentage below statutory minimum | | 8/31/2022 9:28 AM |
| Details | Comments Public | Insert | Hospital Type Change Request | | Participated starting 10/1/2016; Terminated 7/1/2020; Reinstated 10/1/2022. | 8/29/2022 12:57 PM |
| Details | State | Update | | To Be Terminated | Terminated | 7/1/2020 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | OPA Edit Termination Info | 6/1/2020 12:00:00 AM | 7/1/2020 12:00:00 AM | 6/1/2020 2:55 PM |
| Details | State | Update | OPA Edit Termination Info | Terminated | To Be Terminated | 6/1/2020 2:55 PM |
| Terminations | Termination Date | Update | OPA Edit Termination Info | 6/1/2020 12:00:00 AM | 7/1/2020 12:00:00 AM | 6/1/2020 2:55 PM |
| Terminations | Termination Effective Date | Update | OPA Edit Termination Info | 6/1/2020 12:00:00 AM | 7/1/2020 12:00:00 AM | 6/1/2020 2:55 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | OPA Edit Termination Info | 7/1/2020 12:00:00 AM | 6/1/2020 12:00:00 AM | 6/1/2020 11:37 AM |
| Details | State | Update | OPA Edit Termination Info | To Be Terminated | Terminated | 6/1/2020 11:37 AM |
| Terminations | Termination Date | Update | OPA Edit Termination Info | 7/1/2020 12:00:00 AM | 6/1/2020 12:00:00 AM | 6/1/2020 11:37 AM |
| Terminations | Termination Effective Date | Update | OPA Edit Termination Info | 7/1/2020 12:00:00 AM | 6/1/2020 12:00:00 AM | 6/1/2020 11:37 AM |
| Details | Comments Public | Insert | OPA Edit | | “The Office of Pharmacy Affairs recognizes that any Contract Pharmacy for DSH500002 with a termination date of 4/14/2020 is active until 7/1/2020.” | 5/4/2020 12:07 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | OPA Edit Termination Info | 4/14/2020 12:00:00 AM | 7/1/2020 12:00:00 AM | 4/14/2020 5:36 PM |
| Details | State | Update | OPA Edit Termination Info | Terminated | To Be Terminated | 4/14/2020 5:36 PM |
| Terminations | Termination Date | Update | OPA Edit Termination Info | 4/14/2020 12:00:00 AM | 7/1/2020 12:00:00 AM | 4/14/2020 5:36 PM |
| Terminations | Termination Effective Date | Update | OPA Edit Termination Info | 4/14/2020 12:00:00 AM | 7/1/2020 12:00:00 AM | 4/14/2020 5:36 PM |
| Contacts | Primary Contact | Update | | Grimm, Belinda
340B Coordinator
Providence St Mary
5098972087 | Grimm, Belinda
340B Coordinator
Providence St Mary Medical Center
5098972087 | 4/14/2020 4:47 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | OPA Edit Termination Info | 7/1/2020 12:00:00 AM | 4/14/2020 12:00:00 AM | 4/14/2020 12:17 PM |
| Details | State | Update | OPA Edit Termination Info | To Be Terminated | Terminated | 4/14/2020 12:17 PM |
| Terminations | Termination Date | Update | OPA Edit Termination Info | 7/1/2020 12:00:00 AM | 4/14/2020 12:00:00 AM | 4/14/2020 12:17 PM |
| Terminations | Termination Effective Date | Update | OPA Edit Termination Info | 7/1/2020 12:00:00 AM | 4/14/2020 12:00:00 AM | 4/14/2020 12:17 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 7/1/2020 12:00:00 AM | 4/2/2020 7:12 AM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 4/2/2020 7:12 AM |
| Terminations | Termination Comments | Update | Termination Request | | Our DSH percentage has been trending down the past couple of years. We plan to reinstate as an RRC on July 1st to prevent a gap in the 340B program in the event our DSH percentage drops below 11.75 | 4/2/2020 7:12 AM |
| Terminations | Termination Date | Update | Termination Request | | 7/1/2020 12:00:00 AM | 4/2/2020 7:12 AM |
| Terminations | Termination Effective Date | Update | Termination Request | | 7/1/2020 12:00:00 AM | 4/2/2020 7:12 AM |
| Terminations | Termination Reason | Update | Termination Request | | DSH percentage below statutory minimum | 4/2/2020 7:12 AM |
| Addresses | Billing Address | Update | Recertification | PROVIDENCE ST. MARY MEDICAL CENTER
401 W POPLAR ST PO BOX 1477
WALLA WALLA, WA 99362-0000 | PROVIDENCE ACCOUNTS PAYABLE
P.O. BOX 696430
SAN ANTONIO, TX 78269-0000 | 9/15/2019 2:24 PM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 4:42:53 PM | 9/15/2019 2:24:47 PM | 9/15/2019 2:24 PM |
| Contacts | Primary Contact | Update | Change Request | TREIS, ANITA MARIE
DIRECTOR, PHARMACY
Providence St. Mary Medical Center
5098972063 | Grimm, Belinda
340B Coordinator
Providence St Mary
5098972087 | 4/15/2019 2:02 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Blackburn, Susan
CHIEF ADMINISTRATIVE OFFICER
Providence St Mary Medical Center
5098972290 | Blackburn, Susan
CHIEF EXECUTIVE
Providence St Mary Medical Center
5098972290 | 4/15/2019 1:58 PM |
| Details | Last Recertification Date | Update | Recertification | 11/17/2017 3:16:06 PM | 8/22/2018 4:42:53 PM | 8/22/2018 4:42 PM |
| Details | Last Recertification Date | Update | Recertification | | 11/17/2017 3:16:06 PM | 11/17/2017 3:16 PM |
| Contacts | Primary Contact | Update | Recertification | TREIS, ANITA
DIRECTOR, PHARMACY
Providence St. Mary Medical Center
5098972063 | TREIS, ANITA MARIE
DIRECTOR, PHARMACY
Providence St. Mary Medical Center
5098972063 | 11/16/2017 5:27 PM |
| Contacts | Authorizing Official | Update | | Blackburn, Susan
CHIEF ADMINISTRATIVE OFFICER
5098972290 | Blackburn, Susan
CHIEF ADMINISTRATIVE OFFICER
Providence St Mary Medical Center
5098972290 | 9/26/2017 12:08 PM |
| Contacts | Primary Contact | Update | | TREIS, ANITA
DIRECTOR, PHARMACY
5098972063 | TREIS, ANITA
DIRECTOR, PHARMACY
Providence St. Mary Medical Center
5098972063 | 9/25/2017 1:27 PM |
| Contacts | Authorizing Official | Update | | TREIS, ANITA
PHARMACY DIRECTOR
5095225955 | Blackburn, Susan
CHIEF ADMINISTRATIVE OFFICER
5098972290 | 7/18/2017 4:36 PM |
| Addresses | Main Address | Insert | | |
401 W POPLAR ST.
WALLA WALLA, WA 99362-2846 | 7/18/2017 4:35 PM |
| Addresses | Billing Address | Insert | | | PROVIDENCE ST. MARY MEDICAL CENTER
401 W POPLAR ST PO BOX 1477
WALLA WALLA, WA 99362-0000 | 7/18/2017 4:35 PM |
| Contacts | Primary Contact | Update | | TREIS, ANITA
PHARMACY DIRECTOR
5095225955 | TREIS, ANITA
DIRECTOR, PHARMACY
5098972063 | 7/18/2017 4:35 PM |
| Details | Entity Name | Update | | PROV ST MARY MEDICAL CENTER | Providence Health & Services-Washington | 9/15/2016 3:24 PM |
| Details | Entity Subname | Update | | | Providence St. Mary Medical Center | 9/15/2016 3:24 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 9/13/2016 1:44 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 500603798 | 9/13/2016 1:44 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OR | 9/13/2016 1:44 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1386895886 | 9/13/2016 1:44 PM |
| Details | Entity Name | Update | | ST. MARY MEDICAL CENTER | PROV ST MARY MEDICAL CENTER | 9/13/2016 1:44 PM |
| Details | State | Update | | Terminated | Active | 9/13/2016 1:44 PM |
| Dates | Start Date | Update | | 4/1/2006 12:00:00 AM | 10/1/2016 12:00:00 AM | 9/13/2016 1:44 PM |
| Terminations | Termination Date | Update | | 4/1/2007 12:00:00 AM | | 9/13/2016 1:44 PM |
| Terminations | Termination Reason | Update | | DSH percentage below statutory minimum | | 9/13/2016 1:44 PM |
| Details | Comments Public | Insert | | | Participated as DSH starting 4/1/2006, terminated 4/1/2007, then participated as RRC starting 8/11/2010, terminating 10/1/16 when reinstated as a DSH starting 10/1/2016; | 9/13/2016 1:44 PM |
| Contacts | Authorizing Official | Insert | | | TREIS, ANITA
PHARMACY DIRECTOR
5095225955 | 7/3/2014 4:20 PM |
| Contacts | Primary Contact | Insert | | | TREIS, ANITA
PHARMACY DIRECTOR
5095225955 | 7/3/2014 4:20 PM |
| Details | Last Recertification Date | Insert | | | | 3/30/2007 11:08 AM |
| Details | Grant Number | Insert | | | | 3/30/2007 11:08 AM |
| Details | 340B ID | Insert | | | DSH500002 | 3/30/2007 11:08 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 3/30/2007 11:08 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 3/30/2007 11:08 AM |
| Details | Medicare Provider Number | Insert | | | 500002 | 3/30/2007 11:08 AM |
| Details | Entity Name | Insert | | | ST. MARY MEDICAL CENTER | 3/30/2007 11:08 AM |
| Details | Program Code | Insert | | | DSH | 3/30/2007 11:08 AM |
| Details | Entity Subname | Insert | | | | 3/30/2007 11:08 AM |
| Dates | Participating Approval Date | Insert | | | 2/28/2006 12:00:00 AM | 3/30/2007 11:08 AM |
| Details | State | Insert | | | Terminated | 3/30/2007 11:08 AM |
| Dates | Registration Date | Insert | | | 2/27/2006 12:00:00 AM | 3/30/2007 11:08 AM |
| Dates | Signed By Date | Insert | | | 2/7/2006 12:00:00 AM | 3/30/2007 11:08 AM |
| Dates | Start Date | Insert | | | 4/1/2006 12:00:00 AM | 3/30/2007 11:08 AM |
| Terminations | Termination Comments | Insert | | | | 3/30/2007 11:08 AM |
| Terminations | Termination Date | Insert | | | 4/1/2007 12:00:00 AM | 3/30/2007 11:08 AM |
| Terminations | Termination Effective Date | Insert | | | | 3/30/2007 11:08 AM |
| Terminations | Termination Reason | Insert | | | DSH percentage below statutory minimum | 3/30/2007 11:08 AM |
| Details | Comments Public | Insert | | | 3/31/06 - NEW CONTACT | 3/30/2007 11:08 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | True | 2/27/2006 2:20 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 3303104 | 2/27/2006 2:20 PM |
| Medicaid Billing | Medicaid: State | Insert | | | WA | 2/27/2006 2:20 PM |