Covered Entity Details

CAH051328-00 TAHOE FOREST HOSPITAL (Active) - information as of 5/13/2025 10:55:07 PM

Main Details

Name

TAHOE FOREST HOSPITAL

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH051328-00

Medicare Provider Number

051328

Additional Details

Current Program Status

Active

Registration Date

11/11/2010

Participating Start Date

1/1/2011

Participating Approval Date

12/6/2010

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

TAHOE FOREST HOSPITAL DISTRICT
CRYSTAL BETTS, CHIEF FINANCIAL OFFICER
(530) 582-6656

Primary Contact

Tahoe Forest Hospital
Jim L Franckum, Director of Pharmacy
(530) 582-3430

Addresses

Street Address

10121 PINE AVENUE
TRUCKEE, CA 96161

Billing Address

TAHOE FOREST HOSPITAL DISTRICT
P.O. BOX 759
TRUCKEE, CA 96160

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	1538265780,1760038772	1538265780,1760038772

Shipping Addresses

Shipping Address 1

TAHOE FOREST PHARMACY
10956 DONNER PASS ROAD, SUITE 101
101
TRUCKEE, CA 96161

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	07/18/2017	10/01/2017	04/15/2019	04/16/2019
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/18/2017	10/01/2017	04/15/2019	04/16/2019
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/18/2017	10/01/2017	04/15/2019	04/16/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/18/2017	10/01/2017	04/15/2019	04/16/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/18/2017	10/01/2017	04/15/2019	04/16/2019
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/18/2017	10/01/2017	04/15/2019	04/16/2019
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	07/18/2017	10/01/2017	04/15/2019	04/16/2019
Contract Detail	AVELLA OF SACRAMENTO, INC.	2288 AUBURN BLVD #102		SACRAMENTO	CA	95821	12/07/2017	01/01/2018	07/15/2020	07/15/2020
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	10/14/2022	01/01/2023		01/01/2023
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	07/15/2024	10/01/2024		10/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	07/15/2024	10/01/2024		10/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	07/15/2024	10/01/2024		10/01/2024
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09174	11411 DEERFIELD DR	TRUCKEE	CA	96161	10/06/2016	01/01/2017	01/01/2019	01/07/2019
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09174	11411 DEERFIELD DR	TRUCKEE	CA	96161	04/03/2019	07/01/2019	08/31/2021	09/16/2021
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/04/2022	04/01/2022		04/01/2022
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	01/04/2022	04/01/2022		04/01/2022
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/04/2022	04/01/2022		04/01/2022
Contract Detail	OPTUM PHARMACY 803, INC.	701 SHADOW LN #110		LAS VEGAS	NV	89106-4132	07/18/2017	10/01/2017	04/15/2019	04/16/2019
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	07/15/2020	07/15/2020	06/28/2021	06/28/2021
Contract Detail	RALEY'S PHARMACY #113	930 TAHOE BLVD		INCLINE VILLAGE	NV	89451	07/18/2023	10/01/2023	09/11/2023	09/20/2023
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1266	11290 DONNER PASS ROAD	TRUCKEE	CA	96161	01/14/2014	04/01/2014		02/21/2017
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #1592	7815 NORTH LAKE BLVD P.O. BOX 1056	KINGS BEACH	CA	96143	01/05/2018	04/01/2018		01/05/2018
Contract Detail	TAHOE FOREST PHARMACY	10956 DONNER PASS RD	STE 101	TRUCKEE	CA	96161-4861	01/08/2014	04/01/2014	10/31/2023	10/31/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6108	11230 DONNER PASS ROAD	TRUCKEE	CA	96161	10/06/2016	01/01/2017	12/11/2023	12/12/2023
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6106	8245 NORTH LAKE BOULEVARD PO BOX 1175	KINGS BEACH	CA	96143	10/06/2016	01/01/2017	12/11/2023	12/12/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH051328-01	Child	CAH	TAHOE FOREST HOSPITAL	Tahoe Forest Health Clinic	10956 DONNER PASS RD, STE 230	TRUCKEE	CA	Terminated
CAH051328-02	Child	CAH	TAHOE FOREST HOSPITAL	Tahoe Forest MultiSpecialty Clinic - Family & Sports Medicine	10710 DONNER PASS RD	TRUCKEE	CA	Active
CAH051328-03	Child	CAH	TAHOE FOREST HOSPITAL	Tahoe Forest Multi-Specialty Clinics (MOB)	10956 DONNER PASS RD	TRUCKEE	CA	Active
CAH051328-04	Child	CAH	TAHOE FOREST HOSPITAL	Tahoe Forest MultiSpeciality Clinic - Internal Medicine Rural Health	10978 DONNER PASS RD	TRUCKEE	CA	Active
CAH051328-05	Child	CAH	TAHOE FOREST HOSPITAL	Tahoe Forest MultiSpecialty Clinic - Otolaryngology	10956 DONNER PASS RD, STE 340	TRUCKEE	CA	Terminated
CAH051328-06	Child	CAH	TAHOE FOREST HOSPITAL	Tahoe Forest MultiSpecialty Clinic - Primary Care	10956 DONNER PASS RD, STE 130	TRUCKEE	CA	ToBeTerminated
CAH051328-07	Child	CAH	TAHOE FOREST HOSPITAL	Tahoe Forest MultiSpecialty Clinic / Gastroenterology and General Surgery	10956 Donner Pass Road, Suite 210	Truckee	CA	Terminated
CAH051328-08	Child	CAH	TAHOE FOREST HOSPITAL	Tahoe Forest MultiSpecialty Clinic / Urology	10956 Donner Pass Road, Suite 330	Truckee	CA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/12/2023 7:59:41 AM	9/4/2024 7:46:33 AM	9/4/2024 7:46 AM
Addresses	Shipping Address	Insert	Change Request		TAHOE FOREST PHARMACY 10956 DONNER PASS ROAD, SUITE 101 101 TRUCKEE, CA 96161	11/2/2023 8:10 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 12:08:38 PM	9/12/2023 7:59:41 AM	9/12/2023 7:59 AM
Details	Last Recertification Date	Update	Recertification	9/13/2021 6:33:30 AM	9/13/2022 12:08:38 PM	9/13/2022 12:08 PM
Contacts	Primary Contact	Update	Change Request	MATHER, TENA DIRECTOR OF PHARMACY TAHOE FOREST HOSPITAL DISTRICT 5305826465	Franckum, Jim L Director of Pharmacy Tahoe Forest Hospital 5305823430	6/22/2022 12:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/4/2022 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1760038772	5/4/2022 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	5/4/2022 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1760038772	5/4/2022 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	5/4/2022 5:12 PM
Details	Last Recertification Date	Update	Recertification	9/11/2020 8:11:14 AM	9/13/2021 6:33:30 AM	9/13/2021 6:33 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1750412300 (CA)		3/3/2021 6:12 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1750412300 (CA)		3/3/2021 6:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 8:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1538265780	9/11/2020 8:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/11/2020 8:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 8:11 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1750412300	9/11/2020 8:11 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/11/2020 8:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1538265780 ( )		9/11/2020 8:11 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1750412300 ( )		9/11/2020 8:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1538265780	9/11/2020 8:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/11/2020 8:11 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1750412300	9/11/2020 8:11 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/11/2020 8:11 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 8:17:59 AM	9/11/2020 8:11:14 AM	9/11/2020 8:11 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	051328 (CA)		6/12/2020 3:19 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538265780	6/12/2020 3:19 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1750412300	6/12/2020 3:19 PM
Contacts	Primary Contact	Update	Change Request	Sullivan, Christopher Director of Pharmacy Tahoe Forest Hospital District 5305826465	MATHER, TENA DIRECTOR OF PHARMACY TAHOE FOREST HOSPITAL DISTRICT 5305826465	2/10/2020 9:42 AM
Contacts	Primary Contact	Update	Recertification	Cooper, Anthony Scott Director of Pharmacy Tahoe Forest Hospital District 5305826465	Sullivan, Christopher Director of Pharmacy Tahoe Forest Hospital District 5305826465	8/29/2019 8:17 AM
Details	Last Recertification Date	Update	Recertification	8/28/2018 6:08:42 PM	8/29/2019 8:17:59 AM	8/29/2019 8:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/28/2019 11:53 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		051328	6/28/2019 11:53 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	6/28/2019 11:53 AM
Contacts	Primary Contact	Update	Change Request	Vu, Nicholas Director of Pharmacy Tahoe Forest Hospital District 5305826465	Cooper, Anthony Scott Director of Pharmacy Tahoe Forest Hospital District 5305826465	3/19/2019 8:25 AM
Contacts	Primary Contact	Update	Recertification	Cooper, Anthony Scott Director of Pharmacy Tahoe Forest Hospital District 5305826465	Vu, Nicholas Director of Pharmacy Tahoe Forest Hospital District 5305826465	8/28/2018 6:08 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 2:27:31 PM	8/28/2018 6:08:42 PM	8/28/2018 6:08 PM
Contacts	Primary Contact	Update	Change Request	Cooper, Anthony Scott Director of Pharmacy Tahoe Forest Hospital District 5305826465	Cooper, Anthony Scott Director of Pharmacy Tahoe Forest Hospital District 5305826465	1/5/2018 4:25 PM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	12/4/2017 2:27:31 PM	12/4/2017 2:27 PM
Contacts	Primary Contact	Update	Recertification	Cooper, Scott Director of Pharmacy 5305826465	Cooper, Anthony Scott Director of Pharmacy Tahoe Forest Hospital District 5305826465	12/4/2017 2:22 PM
Contacts	Authorizing Official	Update		BETTS, CRYSTAL CHIEF FINANCIAL OFFICER 5305826656	BETTS, CRYSTAL CHIEF FINANCIAL OFFICER TAHOE FOREST HOSPITAL DISTRICT 5305826656	9/27/2017 7:14 PM
Contacts	Authorizing Official	Insert			BETTS, CRYSTAL CHIEF FINANCIAL OFFICER 5305826656	7/18/2017 10:56 AM
Contacts	Primary Contact	Update		Ward, Hilary Director of Pharmacy 5305826372	Cooper, Scott Director of Pharmacy 5305826465	4/5/2017 6:08 PM
Addresses	Main Address	Insert			10121 PINE AVENUE TRUCKEE, CA 96161	4/5/2017 5:47 PM
Addresses	Billing Address	Insert			TAHOE FOREST HOSPITAL DISTRICT P.O. BOX 759 TRUCKEE, CA 96160	4/5/2017 5:47 PM
Contacts	Primary Contact	Update		MATHER, TENA PHARMACY CLINICAL PROGRAM ANALYST 5305826586	Ward, Hilary Director of Pharmacy 5305826372	2/21/2017 12:47 PM
Details	Last Recertification Date	Update		8/28/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 11:09 AM
Contacts	Primary Contact	Insert			MATHER, TENA PHARMACY CLINICAL PROGRAM ANALYST 5305826586	8/28/2015 3:52 PM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	8/28/2015 12:00:00 AM	8/28/2015 3:49 PM
Details	Last Recertification Date	Update		9/5/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 8:34 PM
Details	Last Recertification Date	Update		9/5/2013 6:18:00 PM	9/5/2013 12:00:00 AM	5/2/2014 3:59 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/5/2013 6:18:00 PM	9/5/2013 6:18 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/16/2012 8:21 AM
Details	Last Recertification Date	Insert				12/6/2010 6:22 PM
Details	Grant Number	Insert				12/6/2010 6:22 PM
Details	340B ID	Insert			CAH051328-00	12/6/2010 6:22 PM
Details	Is Authorizing Official EHB Data	Insert				12/6/2010 6:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert				12/6/2010 6:22 PM
Details	Medicare Provider Number	Insert			051328	12/6/2010 6:22 PM
Details	Entity Name	Insert			TAHOE FOREST HOSPITAL	12/6/2010 6:22 PM
Details	Program Code	Insert			CAH	12/6/2010 6:22 PM
Details	Entity Subname	Insert				12/6/2010 6:22 PM
Dates	Participating Approval Date	Insert			12/6/2010 12:00:00 AM	12/6/2010 6:22 PM
Details	State	Insert			Active	12/6/2010 6:22 PM
Dates	Registration Date	Insert			11/11/2010 12:00:00 AM	12/6/2010 6:22 PM
Dates	Signed By Date	Insert			11/11/2010 12:00:00 AM	12/6/2010 6:22 PM
Dates	Start Date	Insert			1/1/2011 12:00:00 AM	12/6/2010 6:22 PM
Terminations	Termination Comments	Insert				12/6/2010 6:22 PM
Terminations	Termination Date	Insert				12/6/2010 6:22 PM
Terminations	Termination Effective Date	Insert				12/6/2010 6:22 PM
Terminations	Termination Reason	Insert				12/6/2010 6:22 PM