Covered Entity Details

CAH051310-00 Willits Hospital Inc., DBA Adventist Health Howard Memorial (Active) - information as of 6/13/2025 2:59:14 PM

Main Details

Name

Willits Hospital Inc., DBA Adventist Health Howard Memorial

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH051310-00

Medicare Provider Number

051310

Additional Details

Current Program Status

Active

Registration Date

8/31/2011

Participating Start Date

10/1/2011

Participating Approval Date

9/27/2011

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Adventist Health North Coast Network
Jeff Mock, Finance Officer, North Coast Network
(916) 406-1417

Primary Contact

Adventist Health Ukiah Valley
Tracy Dolmage, Pharmacy Analyst
(707) 463-7633

Addresses

Street Address

One Marcela Drive
Willits, CA 95490-5769

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
CA	ZZR00440G	1356339543

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ADVENTIST HEALTH HOWARD MEMORIAL	3 MARCELA DR STE B		WILLITS	CA	95490-5769	07/15/2020	10/01/2020	10/13/2021	10/14/2021
Contract Detail	ADVENTIST HEALTH HOWARD PHARMACY	3 MARCELA DR STE B		WILLITS	CA	95490-5769	10/14/2021	10/14/2021		10/15/2021
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	10/15/2024	01/01/2025		01/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	10/15/2024	01/01/2025		01/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	10/15/2024	01/01/2025		01/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	10/15/2024	01/01/2025		01/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	10/15/2024	01/01/2025		01/01/2025
Contract Detail	CRESCENT HEALTHCARE, INC.	25901 INDUSTRIAL BLVD BLDG E		HAYWARD	CA	94545-2995	01/13/2016	04/01/2016	06/04/2023	10/23/2023
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	10/15/2024	01/01/2025		01/01/2025
Contract Detail	MYERS MEDICAL PHARMACY	260 HOSPITAL DR STE 111		UKIAH	CA	95482-4568	08/30/2012	08/30/2012	02/21/2017	01/03/2019
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	11403 BLUEGRASS PARKWAY SUITE 400	LOUISVILLE	KY	40299-2398	01/13/2016	04/01/2016	06/04/2023	12/08/2023
Contract Detail	ORCHARD PHARMACEUTICAL SERVICES		7835 FREEDOM AVENUE	NORTH CANTON	OH	44720-6907	12/03/2012	01/01/2013	10/20/2017	01/03/2019
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	10/15/2024	01/01/2025		01/01/2025
Contract Detail	RALEY'S PHARMACY #328	1315 NORTH STATE STREET		UKIAH	CA	95482	08/17/2012	08/17/2012	10/20/2017	01/25/2019
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	10/15/2024	01/01/2025		01/01/2025
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0978	660 SOUTH MAIN STREET	FORT BRAGG	CA	95437	08/17/2012	08/17/2012	11/01/2015	01/03/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0965	845 SOUTH MAIN STREET	WILLITS	CA	95490	08/17/2012	08/17/2012	11/01/2015	01/03/2019
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0965	845 SOUTH MAIN STREET	WILLITS	CA	95490	10/14/2019	01/01/2020		01/01/2020
Contract Detail	SAFEWAY PHARMACY #4532		90 S MAIN ST	WILLITS	CA	95490	07/12/2013	07/22/2013	11/01/2015	01/03/2019
Contract Detail	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	10/15/2024	01/01/2025		01/01/2025
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6034	1730 SOUTH MAIN STREET	WILLITS	CA	95490	10/28/2016	01/01/2017		10/28/2016
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/12/2018	01/01/2019		01/01/2019
Contract Detail	WAL-MART PHARMACY 10-2052	1155 AIRPORT PARK BLVD.		UKIAH	CA	95482	02/28/2013	04/01/2013		07/28/2015
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/12/2018	01/01/2019		01/01/2019
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/07/2023	10/01/2023		10/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH051310-01	Child	CAH	Willits Hospital Inc., DBA Adventist Health Howard Memorial	Adventist Health Howard Memorial	3 Marcela Drive, Suite C	Willits	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/28/2023 12:35:55 PM	8/19/2024 6:53:33 AM	8/19/2024 6:53 AM
Contacts	Authorizing Official	Update	Change Request	Shepardson, Dean Finance Officer Adventist Health North Coast Network 7074635357	Mock, Jeff Finance Officer, North Coast Network Adventist Health North Coast Network 9164061417	9/27/2023 8:57 AM
Details	Last Recertification Date	Update	Recertification	9/9/2022 9:35:12 AM	8/28/2023 12:35:55 PM	8/28/2023 12:35 PM
Contacts	Primary Contact	Update	Change Request	D'Anis, Matthew DIRECTOR OF PHARMACY Adventist Health Howard Memorial 7074563147	Dolmage, Tracy Pharmacy Analyst Adventist Health Ukiah Valley 7074637633	7/3/2023 6:57 AM
Contacts	Authorizing Official	Update	Change Request	Tetz, Warren Lee Finance Officer Adventist Health Ukiah Valley 7074563001	Shepardson, Dean Finance Officer Adventist Health North Coast Network 7074635357	6/22/2023 7:29 AM
Details	Last Recertification Date	Update	Recertification	8/19/2021 5:07:03 PM	9/9/2022 9:35:12 AM	9/9/2022 9:35 AM
Contacts	Authorizing Official	Update	Change Request	Parker, Bessant Medical Officer Adventist Health Howard Memorial 7074637693	Tetz, Warren Lee Finance Officer Adventist Health Ukiah Valley 7074563001	3/25/2022 12:22 PM
Addresses	Shipping Address	Delete	Change Request	ADVENTIST HEALTH HOWARD MEMORIAL One Marcela Drive Willits, CA 95490-5769		10/15/2021 6:10 AM
Addresses	Shipping Address	Delete	Change Request	ADVENTIST HEALTH HOWARD MEMORIAL 3 Marcela Drive Suite B Willits, CA 95490		10/15/2021 6:10 AM
Details	Last Recertification Date	Update	Recertification	9/7/2020 9:07:53 AM	8/19/2021 5:07:03 PM	8/19/2021 5:07 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/7/2020 9:07 AM
Details	Last Recertification Date	Update	Recertification	8/24/2019 9:21:42 AM	9/7/2020 9:07:53 AM	9/7/2020 9:07 AM
Contacts	Authorizing Official	Update	Change Request	Howe, Judson CFO Adventist Health Howard Memorial 7074563001	Parker, Bessant Medical Officer Adventist Health Howard Memorial 7074637693	8/13/2020 2:09 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 2:33:08 PM	8/24/2019 9:21:42 AM	8/24/2019 9:21 AM
Details	Entity Name	Update	Change Request	Willits Hospital Inc.	Willits Hospital Inc., DBA Adventist Health Howard Memorial	10/25/2018 9:58 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 7:40:48 AM	8/28/2018 2:33:08 PM	8/28/2018 2:33 PM
Contacts	Primary Contact	Update	Profile Change Request	D'Anis, Matthew DIRECTOR OF PHARMACY Adventist Health -Howard Memorial Hospital 7074563147	D'Anis, Matthew DIRECTOR OF PHARMACY Adventist Health Howard Memorial 7074563147	7/11/2018 3:14 PM
Contacts	Signed By	Update		JACOBSON, CARLTON CHIEF FINANCIAL OFFICER 7074563001	JACOBSON, CARLTON Edward CHIEF FINANCIAL OFFICER St Helena Hospital Clearlake 7074563001	11/15/2017 7:14 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/15/2017 7:40:48 AM	11/15/2017 7:40 AM
Addresses	Shipping Address	Insert	Change Request		ADVENTIST HEALTH HOWARD MEMORIAL One Marcela Drive Willits, CA 95490-5769	10/23/2017 9:21 AM
Addresses	Shipping Address	Insert	Change Request		ADVENTIST HEALTH HOWARD MEMORIAL 3 Marcela Drive Suite B Willits, CA 95490	10/23/2017 9:21 AM
Details	Entity Name	Update	Change Request	FRANK R HOWARD MEMORIAL HOSPITAL	Willits Hospital Inc.	10/23/2017 9:21 AM
Contacts	Authorizing Official	Update		Howe, Judson CFO 7074563001	Howe, Judson CFO Adventist Health Howard Memorial 7074563001	10/20/2017 4:08 PM
Contacts	Primary Contact	Update		D'Anis, Matthew DIRECTOR OF PHARMACY 7074563147	D'Anis, Matthew DIRECTOR OF PHARMACY Adventist Health -Howard Memorial Hospital 7074563147	9/29/2017 7:44 PM
Addresses	Shipping Address	Delete		FRANK R HOWARD MEMORIAL HOSPITAL One Marcela Drive Willits, CA 95490-5769		6/5/2017 1:28 PM
Addresses	Shipping Address	Delete		Howard Pharmacy 3 Marcela Drive Suite B Willits, CA 95490		6/5/2017 1:28 PM
Addresses	Main Address	Insert			One Marcela Drive Willits, CA 95490-5769	6/5/2017 1:28 PM
Addresses	Shipping Address	Insert			FRANK R HOWARD MEMORIAL HOSPITAL One Marcela Drive Willits, CA 95490-5769	6/5/2017 1:28 PM
Addresses	Shipping Address	Insert			Howard Pharmacy 3 Marcela Drive Suite B Willits, CA 95490	6/5/2017 1:28 PM
Contacts	Authorizing Official	Update		Scott, Karen VP of Patient Care 7074563010	Howe, Judson CFO 7074563001	6/5/2017 1:28 PM
Contacts	Signed By	Insert			JACOBSON, CARLTON CHIEF FINANCIAL OFFICER 7074563001	6/5/2017 1:28 PM
Contacts	Primary Contact	Update		Lopez, George Interim Director of Pharmacy 7074563147	D'Anis, Matthew DIRECTOR OF PHARMACY 7074563147	6/5/2017 1:28 PM
Contacts	Primary Contact	Update		Forni, Peter DIRECTOR OF PHARMACY 7074563147	Lopez, George Interim Director of Pharmacy 7074563147	5/9/2017 12:01 PM
Contacts	Authorizing Official	Insert			Scott, Karen VP of Patient Care 7074563010	10/28/2016 4:24 PM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 4:09 PM
Contacts	Primary Contact	Update		DANCAUSE-PAULSEN, PAULETTE DIRECTOR OF PHARMACY 7074563131-3039	Forni, Peter DIRECTOR OF PHARMACY 7074563147	12/4/2015 7:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/6/2015 4:10 PM
Medicaid Billing	Medicaid: Number	Insert			ZZR00440G	8/6/2015 4:10 PM
Medicaid Billing	Medicaid: State	Insert			CA	8/6/2015 4:10 PM
Details	Last Recertification Date	Update		8/13/2014 12:00:00 AM	8/6/2015 12:00:00 AM	8/6/2015 4:10 PM
Details	Last Recertification Date	Update		8/20/2013 12:05:08 PM	8/13/2014 12:00:00 AM	8/13/2014 1:50 PM
Details	Last Recertification Date	Update			8/20/2013 12:05:08 PM	8/20/2013 12:05 PM
Contacts	Primary Contact	Insert			DANCAUSE-PAULSEN, PAULETTE DIRECTOR OF PHARMACY 7074563131-3039	11/30/2012 2:33 PM
Dates	Participating Approval Date	Update			9/27/2011 12:00:00 AM	9/27/2011 7:20 PM
Details	State	Update		Pending	Active	9/27/2011 7:20 PM
Dates	Start Date	Update			10/1/2011 12:00:00 AM	9/14/2011 12:39 PM
Details	340B ID	Update		ONLINE_REG	CAH051310-00	9/12/2011 12:05 PM
Medicaid Billing	NPI: Number	Insert			1356339543	8/31/2011 7:17 PM
Details	Last Recertification Date	Insert				8/31/2011 7:17 PM
Details	Grant Number	Insert				8/31/2011 7:17 PM
Details	340B ID	Insert			ONLINE_REG	8/31/2011 7:17 PM
Details	Is Authorizing Official EHB Data	Insert				8/31/2011 7:17 PM
Dates	Last Date That 340B Drugs Purchased	Insert				8/31/2011 7:17 PM
Details	Medicare Provider Number	Insert			051310	8/31/2011 7:17 PM
Details	Entity Name	Insert			FRANK R HOWARD MEMORIAL HOSPITAL	8/31/2011 7:17 PM
Details	Program Code	Insert			CAH	8/31/2011 7:17 PM
Details	Entity Subname	Insert				8/31/2011 7:17 PM
Dates	Participating Approval Date	Insert				8/31/2011 7:17 PM
Details	State	Insert			Pending	8/31/2011 7:17 PM
Dates	Registration Date	Insert			8/31/2011 12:00:00 AM	8/31/2011 7:17 PM
Dates	Signed By Date	Insert			8/31/2011 12:00:00 AM	8/31/2011 7:17 PM
Dates	Start Date	Insert				8/31/2011 7:17 PM
Terminations	Termination Comments	Insert				8/31/2011 7:17 PM
Terminations	Termination Date	Insert				8/31/2011 7:17 PM
Terminations	Termination Effective Date	Insert				8/31/2011 7:17 PM
Terminations	Termination Reason	Insert				8/31/2011 7:17 PM