Covered Entity Details

CAH381317-01 NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER (Active) - information as of 4/28/2025 4:05:42 AM

Main Details

Name

NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER

Subdivision Name

TILLAMOOK MEDICAL GROUP

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH381317-01

Medicare Provider Number

381317

Outpatient Facility Provider Number

388504

Additional Details

Current Program Status

Active

Registration Date

12/9/2010

Participating Start Date

1/1/2011

Participating Approval Date

12/10/2010

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Adventist Health Tillamook
Heather Thompson, Patient Care Executive
(503) 815-2258

Primary Contact

Tillamook Regional Medical Center
KYLE CONNAUGHTON, PHARMACY DIRECTOR
(503) 815-2260

Addresses

Street Address

1100 THIRD STREET
TILLAMOOK, OR 97141

Billing Address

NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER
TILLAMOOK MEDICAL GROUP
1000 THIRD STREET
TILLAMOOK, OR 97141

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?
No

Shipping Addresses

Shipping Address 1

NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER
TILLAMOOK MEDICAL GROUP
1000 THIRD STREET
TILLAMOOK, OR 97141

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	FRED MEYER	2500 NORTH MAIN STREET		TILLAMOOK	OR	97141	12/06/2012	01/01/2013		07/25/2017
Contract Detail	ORCHARD PHARMACEUTICAL SERVICES		7835 FREEDOM AVENUE	NORTH CANTON	OH	44720-6907	12/06/2012	01/01/2013		07/25/2017
Contract Detail	WILSON DRUG INCORPORATED	DBA: TILLAMOOK PHARMACY	915 MAIN AVENUE	TILLAMOOK	OR	97141	08/03/2012	08/03/2012	04/13/2018	05/04/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH381317-01	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	TILLAMOOK MEDICAL GROUP	1100 THIRD STREET	TILLAMOOK	OR	Active
CAH381317-02	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	Adventist Health Tillamook Medical Group Bay Ocean	1011 Third Street	Tillamook	OR	Active
CAH381317-03	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	ADVENTIST HLTH BAYSHORE MED PAC CTY	Adventist Health Bayshore Medical Pacific City	PACIFIC CITY	OR	Active
CAH381317-04	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	Manzanita Urgent, Primary, & Specialty Care	Adventist Health Tillamook Medical Group Manzanita	MANZANITA	OR	Active
CAH381317-05	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	AH Lincoln City - RHC (AHTM)	1105 SE JETTY AVE STE C	LINCOLN CITY	OR	Terminated
CAH381317-06	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	TILLAMOOK REGIONAL MEDICAL CENTER - Long Prairie Clinic (primary care)	5995 LONG PRAIRIE RD	TILLAMOOK	OR	Active
CAH381317-07	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	NORTHWEST MEDICAL FOUNDATION OF TIL - Medical Office - Hoodland	24461 E WELCHES RD	WELCHES	OR	Terminated
CAH381317-08	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	NORTHWEST MEDICAL FOUNDATION OF TIL - Medical Office - Estacada	200 SE HIGHWAY 224	ESTACADA	OR	Active
CAH381317-09	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	NORTHWEST MEDICAL FOUNDATION OF TIL - Medical Office - Banks	12350 NW MAIN ST	BANKS	OR	Terminated
CAH381317-10	Child	CAH	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	NORTHWEST MEDICAL FOUNDATION OF TIL - Medical Office - Vernonia	1005 COUGAR ST	VERNONIA	OR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/21/2023 7:10:10 PM	8/28/2024 5:43:02 PM	8/28/2024 5:43 PM
Details	Last Recertification Date	Update	Recertification	9/7/2022 10:54:39 AM	8/21/2023 7:10:10 PM	8/21/2023 7:10 PM
Contacts	Authorizing Official	Update	Change Request	SAXON, KATHY CNO Tillamook Regional Medical Center 5038152260	Thompson, Heather Patient Care Executive Adventist Health Tillamook 5038152258	4/14/2023 2:36 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 12:23:32 PM	9/7/2022 10:54:39 AM	9/7/2022 10:54 AM
Details	Last Recertification Date	Update	Recertification	9/10/2020 5:15:37 PM	9/9/2021 12:23:32 PM	9/9/2021 12:23 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 12:37:01 PM	9/10/2020 5:15:37 PM	9/10/2020 5:15 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 4:47:27 PM	8/20/2019 12:37:01 PM	8/20/2019 12:37 PM
Details	Last Recertification Date	Update	Recertification	11/21/2017 5:09:10 PM	8/28/2018 4:47:27 PM	8/28/2018 4:47 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	11/21/2017 5:09:10 PM	11/21/2017 5:09 PM
Contacts	Authorizing Official	Update		SAXON, KATHY CNO 5038152260	SAXON, KATHY CNO Tillamook Regional Medical Center 5038152260	11/21/2017 4:15 PM
Contacts	Primary Contact	Update		CONNAUGHTON, KYLE PHARMACY DIRECTOR 5038152260	CONNAUGHTON, KYLE PHARMACY DIRECTOR Tillamook Regional Medical Center 5038152260	10/30/2017 3:07 PM
Addresses	Main Address	Insert			1100 THIRD STREET TILLAMOOK, OR 97141	7/25/2017 10:06 AM
Addresses	Billing Address	Insert			NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER TILLAMOOK MEDICAL GROUP 1000 THIRD STREET TILLAMOOK, OR 97141	7/25/2017 10:06 AM
Addresses	Shipping Address	Insert			NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER TILLAMOOK MEDICAL GROUP 1000 THIRD STREET TILLAMOOK, OR 97141	7/25/2017 10:06 AM
Contacts	Primary Contact	Insert			CONNAUGHTON, KYLE PHARMACY DIRECTOR 5038152260	7/25/2017 10:06 AM
Contacts	Authorizing Official	Insert			SAXON, KATHY CNO 5038152260	7/25/2017 10:06 AM
Details	Last Recertification Date	Update		8/17/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 2:25 PM
Details	Last Recertification Date	Update		8/15/2014 12:00:00 AM	8/17/2015 12:00:00 AM	8/17/2015 5:25 PM
Details	Last Recertification Date	Update		8/22/2013 1:23:36 PM	8/15/2014 12:00:00 AM	8/15/2014 7:31 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/22/2013 1:23:36 PM	8/22/2013 1:23 PM
Details	Entity Name	Update		NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK COUNTY GENERAL HOSPITAL	NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK REGIONAL MEDICAL CENTER	6/11/2013 4:28 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	6/1/2012 9:56 AM
Details	Last Recertification Date	Insert				12/10/2010 7:20 PM
Details	Grant Number	Insert				12/10/2010 7:20 PM
Details	340B ID	Insert			CAH381317-01	12/10/2010 7:20 PM
Details	Is Authorizing Official EHB Data	Insert				12/10/2010 7:20 PM
Dates	Last Date That 340B Drugs Purchased	Insert				12/10/2010 7:20 PM
Details	Medicare Provider Number	Insert			381317	12/10/2010 7:20 PM
Details	Entity Name	Insert			NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK D/B/A TILLAMOOK COUNTY GENERAL HOSPITAL	12/10/2010 7:20 PM
Details	Program Code	Insert			CAH	12/10/2010 7:20 PM
Details	Entity Subname	Insert			TILLAMOOK MEDICAL GROUP	12/10/2010 7:20 PM
Dates	Participating Approval Date	Insert			12/10/2010 12:00:00 AM	12/10/2010 7:20 PM
Details	State	Insert			Active	12/10/2010 7:20 PM
Dates	Registration Date	Insert			12/9/2010 12:00:00 AM	12/10/2010 7:20 PM
Dates	Signed By Date	Insert			9/27/2010 12:00:00 AM	12/10/2010 7:20 PM
Dates	Start Date	Insert			1/1/2011 12:00:00 AM	12/10/2010 7:20 PM
Terminations	Termination Comments	Insert				12/10/2010 7:20 PM
Terminations	Termination Date	Insert				12/10/2010 7:20 PM
Terminations	Termination Effective Date	Insert				12/10/2010 7:20 PM
Terminations	Termination Reason	Insert				12/10/2010 7:20 PM