Covered Entity Details

CAH061328-00 UPPER SAN JUAN HEALTH SERVICE DISTRICT (Active) - information as of 6/25/2025 12:54:47 AM

Main Details

Name

UPPER SAN JUAN HEALTH SERVICE DISTRICT

Subdivision Name

PAGOSA SPRINGS MEDICAL CENTER

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH061328-00

Medicare Provider Number

061328

Additional Details

Current Program Status

Active

Registration Date

2/18/2011

Participating Start Date

4/1/2011

Participating Approval Date

3/2/2011

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Pagosa Springs Medical Center
Chelle Keplinger, CFO
(970) 507-3803

Primary Contact

Pagosa Springs Medical Center
Christina Reeves, Director of Pharmacy
(970) 507-3965

Addresses

Street Address

95 SOUTH PAGOSA BLVD
PAGOSA SPRINGS, CO 81147

Billing Address
Same as Street Address

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
AZ	582810	1245401561
IN	300032220	1245401561
KS	201260790A	1245401561
KY	7100628670	1245401561
NY	06033150	1245401561
OR	500612756	1245401561
TX	37000223,01	1245401561
UT	3013934	1245401561
WA	0353046	1245401561
CO	1645556	1245401561
CA	5408639	1245401561
CT	008056687	1245401561
NM	97170232	1245401561
OK	100820680B	1245401561
VT	0061328	1245401561

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	CITY MARKET PHARMACY #445	165 COUNTRY CENTER DRIVE		PAGOSA SPRINGS	CO	81147	10/20/2011	06/16/2011	03/28/2013
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/15/2021	10/01/2021	10/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/15/2021	10/01/2021	10/01/2021
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/17/2017	10/01/2017	10/01/2017
Contract Detail	WAL-MART PHARMACY 10-2270	1155 SOUTH CAMINO DEL RIO		DURANGO	CO	81303	04/20/2017	07/01/2017	04/20/2017
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/17/2017	10/01/2017	10/01/2017
Contract Detail	WALMART PHARMACY 10-5003	211 ASPEN VILLAGE DRIVE		PAGOSA SPRINGS	CO	81147	04/20/2017	07/01/2017	04/20/2017

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 2:30:22 PM	9/5/2024 11:15:13 AM	9/5/2024 11:15 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 9:45:56 AM	9/5/2023 2:30:22 PM	9/5/2023 2:30 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 10:01:10 AM	9/8/2022 9:45:56 AM	9/8/2022 9:45 AM
Details	Last Recertification Date	Update	Recertification	8/25/2020 7:20:16 AM	8/24/2021 10:01:10 AM	8/24/2021 10:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		582810	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300032220	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		201260790A	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KS	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		7100628670	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		06033150	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		500612756	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		37000223	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		01	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3013934	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		UT	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0353046	8/25/2020 7:20 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		KS	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		VT	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1245401561	8/25/2020 7:20 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/25/2020 7:20 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1245401561 ( )		8/25/2020 7:20 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 7:46:30 AM	8/25/2020 7:20:16 AM	8/25/2020 7:20 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 9:58:29 AM	8/20/2019 7:46:30 AM	8/20/2019 7:46 AM
Details	Last Recertification Date	Update	Recertification	11/8/2017 9:01:32 AM	8/15/2018 9:58:29 AM	8/15/2018 9:58 AM
Contacts	Authorizing Official	Update	Change Request	Lederhouse, Johna Controller Pagosa Springs Medical Center 9705073760	Keplinger, Chelle CFO Pagosa Springs Medical Center 9705073803	8/9/2018 2:04 PM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	11/8/2017 9:01:32 AM	11/8/2017 9:01 AM
Contacts	Authorizing Official	Update		Lederhouse, Johna Controller 9705073760	Lederhouse, Johna Controller Pagosa Springs Medical Center 9705073760	10/20/2017 12:57 PM
Contacts	Primary Contact	Update		Reeves, Christina Director of Pharmacy 9705073965	Reeves, Christina Director of Pharmacy Pagosa Springs Medical Center 9705073965	10/10/2017 6:25 PM
Contacts	Authorizing Official	Update		WILSON, DENNIS CHIEF FINANCIAL OFFICER 9705851411	Lederhouse, Johna Controller 9705073760	7/17/2017 11:34 AM
Addresses	Main Address	Insert			95 SOUTH PAGOSA BLVD PAGOSA SPRINGS, CO 81147	4/4/2017 7:56 AM
Contacts	Primary Contact	Update		Ralston, Kelly Director of Pharmacy 9705851424	Reeves, Christina Director of Pharmacy 9705073965	4/4/2017 7:56 AM
Details	Entity Name	Update		UPPER SAN JUAN HOSPITAL DISTRICT	UPPER SAN JUAN HEALTH SERVICE DISTRICT	4/4/2017 7:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Number	Insert			1645556	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: State	Insert			CO	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Number	Insert			5408639	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: State	Insert			CA	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Number	Insert			008056687	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: State	Insert			CT	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Number	Insert			97170232	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: State	Insert			NM	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Number	Insert			100820680B	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: State	Insert			OK	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: Number	Insert			0061328	10/2/2016 2:43 PM
Medicaid Billing	Medicaid: State	Insert			VT	10/2/2016 2:43 PM
Medicaid Billing	NPI: Number	Insert			1245401561	10/2/2016 2:43 PM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 10:36 AM
Contacts	Primary Contact	Update		Oxford, Patrick Director of Pharmacy 9705851424	Ralston, Kelly Director of Pharmacy 9705851424	9/2/2015 5:59 PM
Contacts	Authorizing Official	Update		WILSON, DENNIS CHIEF FINANCIAL OFFICER 9707313700	WILSON, DENNIS CHIEF FINANCIAL OFFICER 9705851411	9/2/2015 5:59 PM
Details	Last Recertification Date	Update		8/13/2014 12:00:00 AM	9/2/2015 12:00:00 AM	9/2/2015 5:59 PM
Details	Entity Subname	Update		PAGOSA MOUNTAIN HOSPITAL	PAGOSA SPRINGS MEDICAL CENTER	9/2/2015 5:59 PM
Contacts	Primary Contact	Update		Stueve, Randy Director of Pharmacy 9705851424	Oxford, Patrick Director of Pharmacy 9705851424	9/8/2014 7:46 AM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	8/13/2014 12:00:00 AM	8/13/2014 11:37 AM
Contacts	Primary Contact	Update		Stueve, Randy Director of Pharmacy 9707313700	Stueve, Randy Director of Pharmacy 9705851424	7/3/2014 4:20 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/12/2013 12:00:00 AM	9/12/2013 2:59 PM
Contacts	Primary Contact	Update		WILSON, DENNIS CHIEF FINANCIAL OFFICER 9707313700	Stueve, Randy Director of Pharmacy 9707313700	5/31/2012 8:08 AM
Contacts	Authorizing Official	Insert			WILSON, DENNIS CHIEF FINANCIAL OFFICER 9707313700	5/31/2012 8:08 AM
Contacts	Primary Contact	Insert			WILSON, DENNIS CHIEF FINANCIAL OFFICER 9707313700	5/31/2012 8:08 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/31/2012 8:08 AM
Details	Last Recertification Date	Insert				3/3/2011 5:02 PM
Details	Grant Number	Insert				3/3/2011 5:02 PM
Details	340B ID	Insert			CAH061328-00	3/3/2011 5:02 PM
Details	Is Authorizing Official EHB Data	Insert				3/3/2011 5:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert				3/3/2011 5:02 PM
Details	Medicare Provider Number	Insert			061328	3/3/2011 5:02 PM
Details	Entity Name	Insert			UPPER SAN JUAN HOSPITAL DISTRICT	3/3/2011 5:02 PM
Details	Program Code	Insert			CAH	3/3/2011 5:02 PM
Details	Entity Subname	Insert			PAGOSA MOUNTAIN HOSPITAL	3/3/2011 5:02 PM
Dates	Participating Approval Date	Insert			3/2/2011 12:00:00 AM	3/3/2011 5:02 PM
Details	State	Insert			Active	3/3/2011 5:02 PM
Dates	Registration Date	Insert			2/18/2011 12:00:00 AM	3/3/2011 5:02 PM
Dates	Signed By Date	Insert			2/23/2011 12:00:00 AM	3/3/2011 5:02 PM
Dates	Start Date	Insert			4/1/2011 12:00:00 AM	3/3/2011 5:02 PM
Terminations	Termination Comments	Insert				3/3/2011 5:02 PM
Terminations	Termination Date	Insert				3/3/2011 5:02 PM
Terminations	Termination Effective Date	Insert				3/3/2011 5:02 PM
Terminations	Termination Reason	Insert				3/3/2011 5:02 PM