Covered Entity Details

DSH050133B RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout (Active) - information as of 5/14/2025 10:46:57 PM

Main Details

Name

RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout

Subdivision Name

FREMONT-RIDEOUT CANCER CENTER

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050133B

Medicare Provider Number

050133

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/2/2018

Participating Start Date

7/2/2018

Participating Approval Date

7/2/2018

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Adventist Health and Rideout
Gregory Jackson, FO
(530) 751-4049

Primary Contact

Rideout Health
Israel Camacho, 340B Program Coordinator
(559) 723-2514

Addresses

Street Address

618 5TH STREET
MARYSVILLE, CA 95901

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 7/1/2006, terminated 4/1/2018. Reinstated 7/2/2018.	07/02/2018
02/24/2011 ADDED BILL TO ADDR.	02/24/2011

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		1720088354
NV		1720088354
NY		1720088354
OR		1720088354
AZ		1720088354
WA		1720088354

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
DSH050133A	Child	DSH	RIDEOUT MEMORIAL HOSPITAL	FREMONT MEDICAL CENTER	970 PLUMAS STREET	YUBA CITY	CA	Terminated
DSH050133B	Child	DSH	RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout	FREMONT-RIDEOUT CANCER CENTER	618 5TH STREET	MARYSVILLE	CA	Active
DSH050133C	Child	DSH	RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout	FEATHER RIVER SURGERY CENTER	370 DEL NORTE AVE	YUBA CITY	CA	Terminated
DSH050133D	Child	DSH	RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout	Feather River Clinic - Primary Care	5125 Skyway	Paradise	CA	Terminated
DSH050133E	Child	DSH	RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout	Corning Health Center - Primary Care	155 Solano St	Corning	CA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Champlin, Christopher Mathewson President/CEO Adventist Health + Rideout 5307514242	Jackson, Gregory FO Adventist Health and Rideout 5307514049	5/5/2025 12:02 PM
Contacts	Authorizing Official	Update	Change Request	Thordarson, Heidar VP Finance / CFO Adventist Health And Rideout 5307514012	Champlin, Christopher Mathewson President/CEO Adventist Health + Rideout 5307514242	10/21/2024 12:09 PM
Details	Last Recertification Date	Update	Recertification	8/23/2023 6:39:30 PM	8/13/2024 12:19:18 PM	8/13/2024 12:19 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 7:05:47 PM	8/23/2023 6:39:30 PM	8/23/2023 6:39 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 8:10:35 PM	9/6/2022 7:05:47 PM	9/6/2022 7:05 PM
Contacts	Authorizing Official	Update	Change Request	Champlin, Christopher Mathewson President/CEO Adventist Health + Rideout 5307514242	Thordarson, Heidar VP Finance / CFO Adventist Health And Rideout 5307514012	8/8/2022 10:59 AM
Contacts	Authorizing Official	Update	Change Request	Gonzalez, Ed CFO Rideout Memorial Hospital 5307514010	Champlin, Christopher Mathewson President/CEO Adventist Health + Rideout 5307514242	6/13/2022 9:00 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1720088354	5/11/2022 3:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NV	5/11/2022 3:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720088354	5/11/2022 3:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	5/11/2022 3:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720088354	5/11/2022 3:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	5/11/2022 3:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720088354	5/11/2022 3:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	5/11/2022 3:09 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720088354	5/11/2022 3:09 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	5/11/2022 3:09 PM
Details	Last Recertification Date	Update	Recertification	8/19/2020 12:35:05 PM	8/16/2021 8:10:35 PM	8/16/2021 8:10 PM
Contacts	Primary Contact	Update	Profile Change Request	Camacho, Israel 340B Program Coordinator Rideout Health 5307401988	Camacho, Israel 340B Program Coordinator Rideout Health 5597232514	9/2/2020 4:44 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	8/19/2020 12:35 PM
Details	Last Recertification Date	Update	Recertification	8/30/2019 2:12:45 PM	8/19/2020 12:35:05 PM	8/19/2020 12:35 PM
Details	Last Recertification Date	Update	Recertification	8/17/2018 4:41:24 PM	8/30/2019 2:12:45 PM	8/30/2019 2:12 PM
Details	Entity Name	Update	Change Request	RIDEOUT MEMORIAL HOSPITAL	RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout	5/8/2019 6:29 AM
Details	Last Recertification Date	Update	Recertification	11/7/2017 5:46:19 PM	8/17/2018 4:41:24 PM	8/17/2018 4:41 PM
Terminations	Termination Reason	Update		Change of covered entity type		7/21/2018 12:21 PM
Details	State	Update	OPA Edit	Approved	Active	7/2/2018 3:05 PM
Dates	Start Date	Update	OPA Edit	10/1/2018 12:00:00 AM	7/2/2018 12:00:00 AM	7/2/2018 3:05 PM
Contacts	Signed By	Insert	Reinstatement		Gonzalez, Ed CFO Rideout Memorial Hospital 5307514010	7/2/2018 3:04 PM
Contacts	Primary Contact	Update	Reinstatement	Gonzales, Jerry Director of Pharmacy Rideout Health 5307494401	Camacho, Israel 340B Program Coordinator Rideout Health 5307401988	7/2/2018 3:04 PM
Dates	Participating Approval Date	Update	Reinstatement		7/2/2018 3:04:52 PM	7/2/2018 3:04 PM
Details	State	Update	Reinstatement	Pending	Approved	7/2/2018 3:04 PM
Dates	Signed By Date	Update	Reinstatement	2/9/2006 12:00:00 AM	7/2/2018 2:39:06 PM	7/2/2018 3:04 PM
Dates	Start Date	Update	Reinstatement		10/1/2018 12:00:00 AM	7/2/2018 3:04 PM
Terminations	Termination Reason	Update	Reinstatement		Change of covered entity type	7/2/2018 3:04 PM
Contacts	Authorizing Official	Update	Reinstatement	Moon, Diane CFO Rideout Health 5307514260	Gonzalez, Ed CFO Rideout Memorial Hospital 5307514010	7/2/2018 3:02 PM
Details	Comments Public	Insert	Reinstatement		Participated starting 7/1/2006, terminated 4/1/2018. Reinstated 7/2/2018.	7/2/2018 2:54 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	4/1/2018 12:00:00 AM		7/2/2018 12:55 PM
Dates	Participating Approval Date	Update	Reinstatement	5/18/2006 12:00:00 AM		7/2/2018 12:55 PM
Details	State	Update	Reinstatement	Terminated	Pending	7/2/2018 12:55 PM
Dates	Registration Date	Update	Reinstatement	5/17/2006 12:00:00 AM	7/2/2018 12:55:15 PM	7/2/2018 12:55 PM
Dates	Start Date	Update	Reinstatement	7/1/2006 12:00:00 AM		7/2/2018 12:55 PM
Terminations	Termination Date	Update	Reinstatement	4/1/2018 12:00:00 AM		7/2/2018 12:55 PM
Terminations	Termination Effective Date	Update	Reinstatement	4/1/2018 12:00:00 AM		7/2/2018 12:55 PM
Terminations	Termination Reason	Update	Reinstatement	Change of covered entity type		7/2/2018 12:55 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2018 12:00:00 AM	1/25/2018 12:48 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	1/25/2018 12:48 PM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2018 12:00:00 AM	1/25/2018 12:48 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2018 12:00:00 AM	1/25/2018 12:48 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	1/25/2018 12:48 PM
Addresses	Billing Address	Update	Recertification	PO BOX 2128 MARYSVILLE, CA 95901	Fremont Rideout Cancer Center PO BOX 2128 MARYSVILLE, CA 95901	11/7/2017 5:46 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/7/2017 5:46:19 PM	11/7/2017 5:46 PM
Contacts	Primary Contact	Update	Change Request	Arms, Warren H. DIRECTOR OF PHARMACY 5307494417	Gonzales, Jerry Director of Pharmacy Rideout Health 5307494401	10/2/2017 2:22 PM
Contacts	Authorizing Official	Update		Moon, Diane CFO 5307514260	Moon, Diane CFO Rideout Health 5307514260	10/2/2017 1:59 PM
Contacts	Authorizing Official	Update		Burns, Melissa COO 5307494542	Moon, Diane CFO 5307514260	6/6/2017 1:48 PM
Addresses	Main Address	Insert			618 5TH STREET MARYSVILLE, CA 95901	6/6/2017 1:47 PM
Addresses	Billing Address	Insert			PO BOX 2128 MARYSVILLE, CA 95901	6/6/2017 1:47 PM
Contacts	Authorizing Official	Update		GHOSH, TARUN K. CFO 5307514141	Burns, Melissa COO 5307494542	5/3/2017 1:00 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/12/2016 4:09 PM
Contacts	Authorizing Official	Update		Mills, Wayne L. CFO 5307514150	GHOSH, TARUN K. CFO 5307514141	8/10/2015 2:32 PM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 2:32 PM
Contacts	Primary Contact	Update		Kunchandy, Joseph DIRECTOR OF PHARMACY 5307494417	Arms, Warren H. DIRECTOR OF PHARMACY 5307494417	9/8/2014 7:46 AM
Contacts	Authorizing Official	Update		HAMILTON, THERESA CEO 5307514246	Mills, Wayne L. CFO 5307514150	9/8/2014 7:46 AM
Details	Last Recertification Date	Update		8/30/2013 12:00:00 AM	9/3/2014 12:00:00 AM	9/3/2014 9:28 PM
Contacts	Primary Contact	Update		FERRERO, CHRISTINA DIRECTOR OF PHARMACY 5307494417	Kunchandy, Joseph DIRECTOR OF PHARMACY 5307494417	9/3/2014 1:01 PM
Contacts	Authorizing Official	Insert			HAMILTON, THERESA CEO 5307514246	7/3/2014 4:20 PM
Medicaid Billing	NPI: Number	Insert			1720088354	8/30/2013 3:39 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/30/2013 12:00:00 AM	8/30/2013 3:39 PM
Contacts	Primary Contact	Insert			FERRERO, CHRISTINA DIRECTOR OF PHARMACY 5307494417	5/25/2012 10:09 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/25/2012 10:08 AM
Details	Last Recertification Date	Insert				2/24/2011 4:36 PM
Details	Grant Number	Insert				2/24/2011 4:36 PM
Details	340B ID	Insert			DSH050133B	2/24/2011 4:36 PM
Details	Is Authorizing Official EHB Data	Insert				2/24/2011 4:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert				2/24/2011 4:36 PM
Details	Medicare Provider Number	Insert			050133	2/24/2011 4:36 PM
Details	Entity Name	Insert			RIDEOUT MEMORIAL HOSPITAL	2/24/2011 4:36 PM
Details	Program Code	Insert			DSH	2/24/2011 4:36 PM
Details	Entity Subname	Insert			FREMONT-RIDEOUT CANCER CENTER	2/24/2011 4:36 PM
Dates	Participating Approval Date	Insert			5/18/2006 12:00:00 AM	2/24/2011 4:36 PM
Details	State	Insert			Active	2/24/2011 4:36 PM
Dates	Registration Date	Insert			5/17/2006 12:00:00 AM	2/24/2011 4:36 PM
Dates	Signed By Date	Insert			2/9/2006 12:00:00 AM	2/24/2011 4:36 PM
Dates	Start Date	Insert			7/1/2006 12:00:00 AM	2/24/2011 4:36 PM
Terminations	Termination Comments	Insert				2/24/2011 4:36 PM
Terminations	Termination Date	Insert				2/24/2011 4:36 PM
Terminations	Termination Effective Date	Insert				2/24/2011 4:36 PM
Terminations	Termination Reason	Insert				2/24/2011 4:36 PM
Details	Comments Public	Insert			02/24/2011 ADDED BILL TO ADDR.	2/24/2011 4:36 PM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

Parent/Child

History