Covered Entity Details

DSH500150R LEGACY SALMON CREEK HOSPITAL (Active) - information as of 4/29/2025 11:57:59 PM

Main Details

Name

LEGACY SALMON CREEK HOSPITAL

Subdivision Name

Legacy Medical Group Salmon Creek / LMG Salmon Creek IM 625-3961

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500150R

Medicare Provider Number

500150

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

8/27/2012

Participating Start Date

10/1/2012

Participating Approval Date

9/19/2012

Last Recertification Date

9/2/2024

Contacts

Authorizing Official

Legacy Health
Kecia Kelly, SVP Chief Nursing Officer
(503) 415-5199

Primary Contact

Legacy Health
Elena Valcarlos, Pharmacy Systems Manager
(503) 413-7764

Addresses

Street Address

2101 NE 139th Street
460
Vancouver, WA 98686

Billing Address

LEGACY SALMON CREEK MEDICAL CENTER
2211 NE 139TH ST
VANCOUVER, WA 98686

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
OR	027978	1700809829
WA	1016776	1700809829

Shipping Addresses

Shipping Address 1

Legacy Medical Group Salmon Creek
2101 NE 139th St
460
Vancouver, WA 98686

Shipping Address 2

Legacy Salmon Creek Medical Center
2211 NE 139th St
Vancouver, WA 98686

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH500150B	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Computed Tomography / CT Scan 600-3516	2101 NE 139th St	Vancouver	WA	Active
DSH500150C	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Rehabilitation / Rehab 600-3612	2121 NE 139th Street	Vancouver	WA	Active
DSH500150D	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Medication Management Services / Anticoagulation Clinic 600-3719	2121 NE 139th St	Vancouver	WA	Active
DSH500150E	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Fishers Landing	16703 SE McGillivray Blvd, Suite 120	Vancouver	WA	Terminated
DSH500150F	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Radiology / Radiology-Diagnostic 600-3512	2101 NE 139th St	Vancouver	WA	Active
DSH500150G	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Battle Ground	1910 SW 9th Avenue, Suite 100	Battle Ground	WA	Terminated
DSH500150H	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Family Medicine / LMG Salmon Creek Family Med 625-3963	2101 NE 139th St	Vancouver	WA	Active
DSH500150J	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Magnetic Resonance Imaging / MRI 600-3523	2101 NE 139th St	Vancouver	WA	Active
DSH500150K	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Pain Management Center / Pain Mgmt Center 600-3045	2101 NE 139th St	Vancouver	WA	Active
DSH500150L	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Breast Health Center / Mammography Center 600-3520	2101 NE 139th St	Vancouver	WA	Active
DSH500150M	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Nuclear Medicine / Nuclear Medicine 600-3522	2101 NE 139th St	Vancouver	WA	Active
DSH500150N	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Ultrasound / Ultrasound 600-3518	2101 NE 139th St	Vancouver	WA	Active
DSH500150P	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Day Treatment Unit / Day Treatment Clinics 600-3552	2121 NE 139th St	Vancouver	WA	Active
DSH500150Q	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Cardiac Rehabilitation / Cardiac Rehab 600-3440	2121 NE 139th St	Vancouver	WA	Active
DSH500150R	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Salmon Creek / LMG Salmon Creek IM 625-3961	2101 NE 139th Street	Vancouver	WA	Active
DSH500150S	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Wound Ostomy Clinic / Enterostomal Svcs 600-2170	2121 NE 139th St	Vancouver	WA	Active
DSH500150T	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek DTU at the Vancouver Clinic / TVC Infusion Clinic 600-3550	700 NE 87th Ave	Vancouver	WA	Active
DSH500150U	Child	DSH	LEGACY SALMON CREEK HOSPITAL	LEGACY MEDICAL GROUP GYNECOLOGIC ONCOLOGY-SALMON CREEK MEDICAL CENTER - GYNECOLOGIC ONCOLOGY	2121 NE 139th St	Vancouver	WA	Terminated
DSH500150V	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Oncology at the Vancouver Clinic / TVC Infusion Clinic 600-3550	700 NE 87th Ave	Vancouver	WA	Active
DSH500150W	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Diabetes Services / LMG Salmon Creek IM 625-3961	2101 NE 139th St	Vancouver	WA	Active
DSH500150X	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Geriatrics Salmon Creek / LMG Salmon Creek IM 625-3961	2101 NE 139th St	Vancouver	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Tanas, Majid VP Pharmacy Services Legacy Health 5034155011	Kelly, Kecia SVP Chief Nursing Officer Legacy Health 5034155199	9/16/2024 7:42 AM
Addresses	Main Address	Update	Recertification	2101 NE 139th Street Medical Office Building B 460 Vancouver, WA 98686	2101 NE 139th Street 460 Vancouver, WA 98686	9/2/2024 10:46 AM
Details	Last Recertification Date	Update	Recertification	9/11/2023 10:48:36 AM	9/2/2024 10:46:33 AM	9/2/2024 10:46 AM
Addresses	Shipping Address	Insert	Recertification		Legacy Medical Group Salmon Creek 2101 NE 139th St 460 Vancouver, WA 98686	9/11/2023 10:48 AM
Addresses	Shipping Address	Insert	Recertification		Legacy Salmon Creek Medical Center 2211 NE 139th St Vancouver, WA 98686	9/11/2023 10:48 AM
Addresses	Main Address	Update	Recertification	2101 NE 139th Street 460 Vancouver, WA 98686	2101 NE 139th Street Medical Office Building B 460 Vancouver, WA 98686	9/11/2023 10:48 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 1:09:10 PM	9/11/2023 10:48:36 AM	9/11/2023 10:48 AM
Details	Entity Subname	Update	Recertification	Legacy Medical Group Salmon Creek / Legacy Clinic Salmon Creek 625-3961	Legacy Medical Group Salmon Creek / LMG Salmon Creek IM 625-3961	9/11/2023 10:48 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 7:01:24 PM	9/8/2022 1:09:10 PM	9/8/2022 1:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		027978	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OR	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1016776	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WA	6/13/2022 6:49 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700809829	6/13/2022 6:49 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OR	6/13/2022 6:49 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700809829	6/13/2022 6:49 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WA	6/13/2022 6:49 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 10:14:45 AM	9/9/2021 7:01:24 PM	9/9/2021 7:01 PM
Contacts	Authorizing Official	Update	Change Request	Loomis, Anna SVP Chief Financial Officer Legacy Health 5034155730	Tanas, Majid VP Pharmacy Services Legacy Health 5034155011	1/25/2021 10:45 AM
Addresses	Main Address	Update	Recertification	2101 NE 139th Street, Suite 460 Vancouver, WA 98686	2101 NE 139th Street 460 Vancouver, WA 98686	9/8/2020 10:14 AM
Details	Last Recertification Date	Update	Recertification	9/6/2019 8:16:31 PM	9/8/2020 10:14:45 AM	9/8/2020 10:14 AM
Details	Entity Subname	Update	Recertification	Legacy Medical Group Salmon Creek Internal Medicine	Legacy Medical Group Salmon Creek / Legacy Clinic Salmon Creek 625-3961	9/8/2020 10:14 AM
Contacts	Primary Contact	Update	Profile Change Request	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034137764	Valcarlos, Elena Pharmacy Systems Manager Legacy Health 5034137764	1/31/2020 4:08 PM
Contacts	Primary Contact	Update	Profile Change Request	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034131321	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034137764	1/31/2020 4:08 PM
Contacts	Authorizing Official	Update	Change Request	Bradley, Carol SVP and Chief Nursing Officer Legacy Health 5034155199	Loomis, Anna SVP Chief Financial Officer Legacy Health 5034155730	9/15/2019 1:43 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 7:53:15 AM	9/6/2019 8:16:31 PM	9/6/2019 8:16 PM
Contacts	Primary Contact	Update	Change Request	Stoner, Kathleen C. Vice President Supply Chain and Pharmacy Services Legacy Health 5039444276	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034131321	8/13/2019 7:10 AM
Contacts	Authorizing Official	Update	AO Change Request	Newcomb III, Everett W. Sr Vice President and COO Legacy Health 5034155252	Bradley, Carol SVP and Chief Nursing Officer Legacy Health 5034155199	12/31/2018 7:19 AM
Contacts	Primary Contact	Update	Profile Change Request	Stoner, Kathleen C. Director, LH Pharmacy Services Legacy Health 5034136926	Stoner, Kathleen C. Vice President Supply Chain and Pharmacy Services Legacy Health 5039444276	9/7/2018 1:25 PM
Addresses	Shipping Address	Delete	Recertification	LEGACY SALMON CREEK MEDICAL CENTER 2211 NE 139TH ST VANCOUVER, WA 98686		8/24/2018 7:53 AM
Details	Last Recertification Date	Update	Recertification	11/17/2017 2:51:12 PM	8/24/2018 7:53:15 AM	8/24/2018 7:53 AM
Details	Entity Name	Update	Recertification	LEGACY SALMON CREEK MEDICAL CENTER	LEGACY SALMON CREEK HOSPITAL	11/17/2017 3:16 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/17/2017 2:51:12 PM	11/17/2017 2:51 PM
Contacts	Authorizing Official	Update		Newcomb III, Everett W. Sr Vice President and COO 5034155252	Newcomb III, Everett W. Sr Vice President and COO Legacy Health 5034155252	10/11/2017 1:31 PM
Contacts	Primary Contact	Update		Stoner, Kathleen C. Director, LH Pharmacy Services 5034136926	Stoner, Kathleen C. Director, LH Pharmacy Services Legacy Health 5034136926	10/11/2017 12:40 PM
Contacts	Primary Contact	Insert			Stoner, Kathleen C. Director, LH Pharmacy Services 5034136926	6/12/2017 2:32 PM
Contacts	Authorizing Official	Insert			Newcomb III, Everett W. Sr Vice President and COO 5034155252	6/12/2017 2:32 PM
Contacts	Signed By	Insert			Eager, David E. Sr. VP and CFO, Legacy Health 5034155730	6/12/2017 2:32 PM
Addresses	Main Address	Insert			2101 NE 139th Street, Suite 460 Vancouver, WA 98686	8/31/2016 5:53 PM
Details	Last Recertification Date	Update		9/1/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 5:53 PM
Addresses	Billing Address	Insert			LEGACY SALMON CREEK MEDICAL CENTER 2211 NE 139TH ST VANCOUVER, WA 98686	6/28/2016 8:11 AM
Addresses	Shipping Address	Insert			LEGACY SALMON CREEK MEDICAL CENTER 2211 NE 139TH ST VANCOUVER, WA 98686	6/28/2016 8:11 AM
Details	Entity Subname	Update		Legacy Salmon Creek Medical Group	Legacy Medical Group Salmon Creek Internal Medicine	6/28/2016 8:11 AM
Details	Last Recertification Date	Update		8/27/2014 12:00:00 AM	9/1/2015 12:00:00 AM	9/1/2015 6:06 PM
Details	Last Recertification Date	Update		9/9/2013 9:36:03 PM	8/27/2014 12:00:00 AM	8/27/2014 11:01 AM
Details	Last Recertification Date	Update			9/9/2013 9:36:03 PM	9/9/2013 9:36 PM
Details	340B ID	Update		IS-DR-DSH500150R	DSH500150R	9/19/2012 4:29 PM
Dates	Participating Approval Date	Update			9/19/2012 12:00:00 AM	9/19/2012 4:29 PM
Details	State	Update		Pending	Active	9/19/2012 4:29 PM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	9/19/2012 4:29 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-DR-DSH500150R	9/17/2012 12:11 PM
Details	Last Recertification Date	Insert				8/27/2012 4:35 PM
Details	Grant Number	Insert				8/27/2012 4:35 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	8/27/2012 4:35 PM
Details	Is Authorizing Official EHB Data	Insert				8/27/2012 4:35 PM
Dates	Last Date That 340B Drugs Purchased	Insert				8/27/2012 4:35 PM
Details	Medicare Provider Number	Insert			500150	8/27/2012 4:35 PM
Details	Entity Name	Insert			LEGACY SALMON CREEK MEDICAL CENTER	8/27/2012 4:35 PM
Details	Program Code	Insert			DSH	8/27/2012 4:35 PM
Details	Entity Subname	Insert			Legacy Salmon Creek Medical Group	8/27/2012 4:35 PM
Dates	Participating Approval Date	Insert				8/27/2012 4:35 PM
Details	State	Insert			Pending	8/27/2012 4:35 PM
Dates	Registration Date	Insert			8/27/2012 12:00:00 AM	8/27/2012 4:35 PM
Dates	Signed By Date	Insert			8/27/2012 12:00:00 AM	8/27/2012 4:35 PM
Dates	Start Date	Insert				8/27/2012 4:35 PM
Terminations	Termination Comments	Insert				8/27/2012 4:35 PM
Terminations	Termination Date	Insert				8/27/2012 4:35 PM
Terminations	Termination Effective Date	Insert				8/27/2012 4:35 PM
Terminations	Termination Reason	Insert				8/27/2012 4:35 PM