Covered Entity Details

DSH050017 MERCY GENERAL HOSPITAL (Active) - information as of 4/29/2025 12:33:37 AM

Main Details

Name

MERCY GENERAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050017

Medicare Provider Number

050017

Additional Details

Current Program Status

Active

Registration Date

10/17/2007

Participating Start Date

4/1/2005

Participating Approval Date

10/17/2007

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

CommonSpirit
Charles Thevnin, VP/CFO - Sac Market
(916) 423-6100

Primary Contact

CommonSpirit Health
Ryan Pearcy, 340B Region Manager
(859) 229-5654

Addresses

Street Address

4001 J STREET
SACRAMENTO, CA 95819

Billing Address

Dignity Health AP SAC
3400 Data Drive
Rancho Cordova, CA 95670

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	ZZR00017H	1487694857

Shipping Addresses

Shipping Address 1

Mercy General Hospital
4001 J Street
Sacramento, CA 95819

Shipping Address 2

Safecor Health LLC
4060 Business Park Drive Suite B
Columbus, OH 43204

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	08/07/2019	10/01/2019	05/30/2022	08/10/2023
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	08/07/2019	10/01/2019	05/30/2022	08/10/2023
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	08/07/2019	10/01/2019	05/30/2022	08/10/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	08/07/2019	10/01/2019	05/30/2022	08/10/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	08/07/2019	10/01/2019	05/30/2022	08/10/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	08/07/2019	10/01/2019	05/30/2022	08/10/2023
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	10/11/2019	01/01/2020	05/30/2022	08/10/2023
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	10/11/2019	01/01/2020	05/30/2022	08/10/2023
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/11/2019	01/01/2020	01/01/2020	03/04/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/11/2019	01/01/2020	05/30/2022	08/10/2023
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/11/2019	01/01/2020	05/30/2022	08/10/2023
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	10/11/2019	01/01/2020	05/30/2022	08/10/2023
Contract Detail	OPTUM PHARMACY 800, INC.	3016 GUADALUPE ST STE A		AUSTIN	TX	78705-2861	10/11/2019	01/01/2020	05/30/2022	08/10/2023
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	10/11/2019	01/01/2020	05/30/2022	08/10/2023
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	10/11/2019	01/01/2020	05/30/2022	08/10/2023
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	ST JOSEPH'S MCAULEY PHARMACY	500 W. THOMAS ROAD	SUITE 190	PHOENIX	AZ	85013	04/04/2019	07/01/2019	03/21/2024	05/21/2024
Contract Detail	WAL-MART PHARMACY 10-2598	3661 TRUXEL ROAD		SACRAMENTO (NW)	CA	95833	08/08/2019	10/01/2019	09/26/2019	09/26/2019
Contract Detail	WAL-MART PHARMACY 10-2598	3661 TRUXEL ROAD		SACRAMENTO (NW)	CA	95833	10/08/2019	01/01/2020	07/21/2023	08/10/2023
Contract Detail	WAL-MART PHARMACY 10-2735	6051 FLORIN ROAD		SACRAMENTO	CA	95823	08/08/2019	10/01/2019	09/26/2019	09/26/2019
Contract Detail	WAL-MART PHARMACY 10-2735	6051 FLORIN ROAD		SACRAMENTO	CA	95823	10/08/2019	01/01/2020	07/21/2023	08/10/2023
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	08/08/2019	10/01/2019	09/26/2019	09/26/2019
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	10/08/2019	01/01/2020	07/21/2023	08/10/2023
Contract Detail	WALGREEN CO	DBA: WALGREENS #10114	3521 DEL PASO ROAD	SACRAMENTO	CA	95835	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #10693	6819 WATT AVE	NORTH HIGHLANDS	CA	95660-3203	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #07191	6199 SUNRISE BOULEVARD	CITRUS HEIGHTS	CA	95610	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	WALGREEN CO	DBA: WALGREENS #10716	250 FLORIN RD	SACRAMENTO	CA	95831	10/08/2019	01/01/2020	01/10/2022	05/17/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #02170	12120 NEW AIRPORT RD	AUBURN	CA	95603	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04136	1919 FRUITRIDGE RD.	SACRAMENTO	CA	95822	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04170	4200 ARDEN WAY	SACRAMENTO	CA	95864	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04198	1351 W CAPITOL AVE	WEST SACRAMENTO	CA	95691	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05036	4495 MACK RD	SACRAMENTO	CA	95823	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05152	6144 DEWEY DRIVE	CITRUS HEIGHTS	CA	95621	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05374	2900 STOCKTON BLVD	SACRAMENTO	CA	95817	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05499	7299 LAGUNA BLVD	ELK GROVE	CA	95758	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05500	4331 ANTELOPE ROAD	SACRAMENTO	CA	95843	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06193	2201 ARDEN WAY	SACRAMENTO	CA	95825	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06419	9180 FRANKLIN BLVD	ELK GROVE	CA	95758	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06612	8400 ELK GROVE FLORIN ROAD	ELK GROVE	CA	95624-9450	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06613	1401 BROADWAY	SACRAMENTO	CA	95818	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06706	7155 24TH STREET	SACRAMENTO	CA	95822	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11262	840 EL CAMINO AVE	SACRAMENTO	CA	95815-2513	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12365	8275 BRUCEVILLE RD	SACRAMENTO	CA	95823	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04136	1919 FRUITRIDGE RD.	SACRAMENTO	CA	95822	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04170	4200 ARDEN WAY	SACRAMENTO	CA	95864	10/08/2019	01/01/2020	01/10/2022	05/17/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05152	6144 DEWEY DRIVE	CITRUS HEIGHTS	CA	95621	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05374	2900 STOCKTON BLVD	SACRAMENTO	CA	95817	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05499	7299 LAGUNA BLVD	ELK GROVE	CA	95758	10/08/2019	01/01/2020	01/10/2022	05/17/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06193	2201 ARDEN WAY	SACRAMENTO	CA	95825	10/08/2019	01/01/2020	01/10/2022	05/17/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06613	1401 BROADWAY	SACRAMENTO	CA	95818	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11262	840 EL CAMINO AVE	SACRAMENTO	CA	95815-2513	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	10/16/2013	01/01/2014	07/01/2015	07/21/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	10/08/2019	01/01/2020	10/01/2021	11/08/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/08/2019	01/01/2020	10/25/2021	11/08/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/08/2019	01/01/2020	10/25/2021	11/08/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050017A	Child	DSH	MERCY GENERAL HOSPITAL	Outpatient Surgery Center	3941 J Street	Sacramento	CA	Active
DSH050017B	Child	DSH	MERCY GENERAL HOSPITAL	OP Imaging	3941 J Street	Sacramento	CA	Active
DSH050017C	Child	DSH	MERCY GENERAL HOSPITAL	Electrophysiology Labs	3941 J Street	Sacramento	CA	Active
DSH050017D	Child	DSH	MERCY GENERAL HOSPITAL	Lucchetti Anderson Cardiovascular Center - Cardiovascular Clinic	3939 J Street	Sacramento	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Thevnin, Charles VP/CFO - Sac Market CommonSpirit 9164233000	Thevnin, Charles VP/CFO - Sac Market CommonSpirit 9164236100	1/28/2025 2:55 PM
Contacts	Primary Contact	Update	Change Request	Nguyen, Tammie Pharmacy Director Mercy General Hospital 9164534596	Pearcy, Ryan 340B Region Manager CommonSpirit Health 8592295654	11/26/2024 3:19 PM
Contacts	Authorizing Official	Update	Change Request	Engbritson, Paul Michael CFO Dignity Health 9167336311	Thevnin, Charles VP/CFO - Sac Market CommonSpirit 9164233000	11/4/2024 10:43 AM
Details	Last Recertification Date	Update	Recertification	8/17/2023 4:26:48 PM	8/15/2024 12:11:06 PM	8/15/2024 12:11 PM
Details	Last Recertification Date	Update	Recertification	8/25/2022 1:51:07 PM	8/17/2023 4:26:48 PM	8/17/2023 4:26 PM
Contacts	Authorizing Official	Update	Change Request	Jenkins, Bonnie Helen CFO Mercy General Hospital 9164534459	Engbritson, Paul Michael CFO Dignity Health 9167336311	1/23/2023 7:08 AM
Details	Last Recertification Date	Update	Recertification	8/23/2021 7:16:05 AM	8/25/2022 1:51:07 PM	8/25/2022 1:51 PM
Details	Last Recertification Date	Update	Recertification	8/19/2020 7:16:49 AM	8/23/2021 7:16:05 AM	8/23/2021 7:16 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	8/19/2020 7:16 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 10:43:40 AM	8/19/2020 7:16:49 AM	8/19/2020 7:16 AM
Addresses	Shipping Address	Insert	Change Request		Mercy General Hospital 4001 J Street Sacramento, CA 95819	3/23/2020 2:41 PM
Addresses	Shipping Address	Insert	Change Request		Safecor Health LLC 4060 Business Park Drive Suite B Columbus, OH 43204	3/23/2020 2:41 PM
Contacts	Primary Contact	Update	Profile Change Request	Nguyen, Tammie Pharmacy Manager Mercy General Hospital 9164534596	Nguyen, Tammie Pharmacy Director Mercy General Hospital 9164534596	3/20/2020 11:26 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 1:44:05 PM	8/26/2019 10:43:40 AM	8/26/2019 10:43 AM
Contacts	Primary Contact	Update	Change Request	Nehira, Jeffrey Director of Pharmacy Dignity Health 9164534907	Nguyen, Tammie Pharmacy Manager Mercy General Hospital 9164534596	10/10/2018 6:53 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 12:57:26 PM	8/15/2018 1:44:05 PM	8/15/2018 1:44 PM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/29/2017 12:57:26 PM	11/29/2017 12:57 PM
Contacts	Authorizing Official	Update		Jenkins, Bonnie CFO 9164534459	Jenkins, Bonnie Helen CFO Mercy General Hospital 9164534459	10/20/2017 9:41 AM
Contacts	Primary Contact	Update		Nehira, Jeffrey Director of Pharmacy 9164534907	Nehira, Jeffrey Director of Pharmacy Dignity Health 9164534907	10/9/2017 1:06 PM
Addresses	Main Address	Insert			4001 J STREET SACRAMENTO, CA 95819	7/21/2017 4:52 PM
Addresses	Billing Address	Insert			Dignity Health AP SAC 3400 Data Drive Rancho Cordova, CA 95670	7/21/2017 4:52 PM
Contacts	Primary Contact	Update		Schaad, Allen Director of Pharmacy 9164534459	Nehira, Jeffrey Director of Pharmacy 9164534907	7/21/2017 4:52 PM
Contacts	Authorizing Official	Update		Winegarner, Rodney B. CFO 9164534459	Jenkins, Bonnie CFO 9164534459	7/21/2017 4:52 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 1:04 PM
Details	Last Recertification Date	Update		8/21/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 11:44 AM
Medicaid Billing	Medicaid: Number	Update		050017	ZZR00017H	3/11/2015 8:14 AM
Details	Last Recertification Date	Update		9/5/2013 12:00:00 AM	8/21/2014 12:00:00 AM	8/21/2014 12:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/20/2014 10:21 AM
Medicaid Billing	Medicaid: Number	Insert			050017	3/20/2014 10:21 AM
Medicaid Billing	Medicaid: State	Insert			CA	3/20/2014 10:21 AM
Medicaid Billing	NPI: Number	Insert			1487694857	3/20/2014 10:21 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/5/2013 12:00:00 AM	9/5/2013 5:27 PM
Contacts	Primary Contact	Update		Winegarner, Rodney B. CFO 9164534459	Schaad, Allen Director of Pharmacy 9164534459	4/15/2013 4:09 PM
Contacts	Authorizing Official	Insert			Winegarner, Rodney B. CFO 9164534459	3/29/2013 11:41 AM
Contacts	Primary Contact	Insert			Winegarner, Rodney B. CFO 9164534459	3/29/2013 11:41 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/2/2012 7:57 AM
Dates	Participating Approval Date	Update		10/17/2007 2:30:04 PM	10/17/2007 12:00:00 AM	3/14/2012 9:33 AM
Details	Last Recertification Date	Insert				10/17/2007 2:32 PM
Details	Grant Number	Insert				10/17/2007 2:32 PM
Details	340B ID	Insert			DSH050017	10/17/2007 2:32 PM
Details	Is Authorizing Official EHB Data	Insert				10/17/2007 2:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/17/2007 2:32 PM
Details	Medicare Provider Number	Insert			050017	10/17/2007 2:32 PM
Details	Entity Name	Insert			MERCY GENERAL HOSPITAL	10/17/2007 2:32 PM
Details	Program Code	Insert			DSH	10/17/2007 2:32 PM
Details	Entity Subname	Insert				10/17/2007 2:32 PM
Dates	Participating Approval Date	Insert			10/17/2007 2:30:04 PM	10/17/2007 2:32 PM
Details	State	Insert			Active	10/17/2007 2:32 PM
Dates	Registration Date	Insert			10/17/2007 12:00:00 AM	10/17/2007 2:32 PM
Dates	Signed By Date	Insert			5/13/2004 12:00:00 AM	10/17/2007 2:32 PM
Dates	Start Date	Insert			4/1/2005 12:00:00 AM	10/17/2007 2:32 PM
Terminations	Termination Comments	Insert				10/17/2007 2:32 PM
Terminations	Termination Date	Insert				10/17/2007 2:32 PM
Terminations	Termination Effective Date	Insert				10/17/2007 2:32 PM
Terminations	Termination Reason	Insert				10/17/2007 2:32 PM