Covered Entity Details

DSH380022C SAMARITAN ALBANY GENERAL HOSPITAL (Active) - information as of 6/1/2025 4:01:04 AM

Main Details

Name

SAMARITAN ALBANY GENERAL HOSPITAL

Subdivision Name

SAGH Geary Street Family Practice

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH380022C

Medicare Provider Number

380022

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/3/2012

Participating Start Date

1/1/2013

Participating Approval Date

10/18/2012

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

Samaritan Albany General Hospital
DANIEL B. SMITH, VP FINANCE/CFO
(541) 768-5390

Primary Contact

Samaritan Lebanon Community Hospital
Daniel Rackham, Chief Executive Officer
(541) 451-7914

Addresses

Street Address

1700 Geary Street SE
Suite 200 & 300A
Albany, OR 97322

Billing Address

Samaritan Health Services, Inc.
PO BOX 3000
Corvallis, OR 97339

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	500651474,292	1154372340,1972879518

Shipping Addresses

Shipping Address 1

SAMARITAN ALBANY GENERAL HOSPITAL
1046 6th Ave SW
Albany, OR 97321

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
DSH380022A	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Breast Surgical Specialists	631 Elm Street SW	Albany	OR	Terminated
DSH380022B	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Cardiology Clinic	631 Elm Street SW	Albany	OR	Active
DSH380022C	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Geary Street Family Practice	1700 Geary Street SE	Albany	OR	Active
DSH380022D	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Heart and Rhythm Center	620 Elm Street Southwest	Albany	OR	Terminated
DSH380022E	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Hematology and Oncology	1086 7th Avenue SW	Albany	OR	Active
DSH380022F	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Urgent Care Geary Street	1700 Geary Street SE	Albany	OR	Active
DSH380022G	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Internal Medicine	1086 Southwest 7th Street	Albany	OR	Terminated
DSH380022H	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Mid-Valley Children's Clinic	734 SW Elm Street	Albany	OR	Terminated
DSH380022J	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH North Albany Cardiology Clinic	400 NW Hickory Street Suite 300	Albany	OR	Terminated
DSH380022K	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH North Albany Medical Clinic	400 Hickory Street NW	Albany	OR	Active
DSH380022L	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Surgical Associates	705 Elm Street Southwest Suite 300	Albany	OR	Terminated
DSH380022M	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	Ambulatory Infusion - Neville	3615 NW Samaritan Drive Suite G-12	Corvallis	OR	Terminated
DSH380022N	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Urgent Care - North Albany	400 Hickory Street NW	Albany	OR	Active
DSH380022P	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	Hospice	4600 Evergreen Place SE	Albany	OR	Active
DSH380022Q	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	Wound Ostomy	400 NW Hickory Street	Albany	OR	Terminated
DSH380022R	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Ultrasound	400 Hickory Street NW	Albany	OR	Active
DSH380022S	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	AGH Medication Management - Geary St	1700 GEARY ST SE	ALBANY	OR	Active
DSH380022T	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Imaging Services	400 Hickory Street NW	ALBANY	OR	Active
DSH380022U	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	SAGH Ambulatory Infusion	1086 7th Avenue SW	Albany	OR	Active
DSH380022V	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	AGH Medication Management - Hickory St	400 Hickory Street NW	ALBANY	OR	Active
DSH380022W	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	ALBANY GENERAL HOSPITAL / AGH Anticoag C 7th Ave	1086 7TH AVE SW	ALBANY	OR	Terminated
DSH380022X	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	AGH Mammography - AGH Mammography	400 Hickory Street NW, Suite 100	Albany	OR	Active
DSH380022Y	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	AGH Hospice Outpatient Coastal - AGH Hospice Outpatient Coastal	749 SW 11th St	Newport	OR	Active
DSH380022Z	Child	DSH	SAMARITAN ALBANY GENERAL HOSPITAL	AGH Diabetes Management - AGH Diabetes Management	620 Elm Street SW	Albany	OR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Rackham, Daniel Chief Executive Officer Samaritan Lebanon Community Hospital 5414517107	Rackham, Daniel Chief Executive Officer Samaritan Lebanon Community Hospital 5414517914	10/9/2024 10:28 AM
Contacts	Primary Contact	Update	Profile Change Request	Rackham, Daniel Chief Pharmacy Officer Samaritan Health Services 5417686177	Rackham, Daniel Chief Executive Officer Samaritan Lebanon Community Hospital 5414517107	10/8/2024 1:41 PM
Details	Last Recertification Date	Update	Recertification	8/28/2023 7:11:03 PM	8/23/2024 4:13:13 PM	8/23/2024 4:13 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 1:20:48 PM	8/28/2023 7:11:03 PM	8/28/2023 7:11 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	25527 (OR)		4/13/2023 1:28 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 10:06:30 AM	8/30/2022 1:20:48 PM	8/30/2022 1:20 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500673023 (OR)		4/7/2022 5:20 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1558776047 (OR)		4/7/2022 5:20 PM
Contacts	Primary Contact	Update	Change Request	Douglas, Joy R Rx data Coordinator - 340B Contract Pharmacy Samaritan Health Services 5417686867	Rackham, Daniel Chief Pharmacy Officer Samaritan Health Services 5417686177	1/12/2022 6:54 AM
Addresses	Main Address	Update	Recertification	1700 Geary Street SE Suite 200 & 300A Albany, OR 97321	1700 Geary Street SE Suite 200 & 300A Albany, OR 97322	9/9/2021 10:06 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 4:23:03 PM	9/9/2021 10:06:30 AM	9/9/2021 10:06 AM
Addresses	Main Address	Update	Change Request	1700 Geary Street SE Albany, OR 97321	1700 Geary Street SE Suite 200 & 300A Albany, OR 97321	4/27/2021 8:03 AM
Details	Entity Subname	Update	Change Request	SAGH Geary Street Family Pracice	SAGH Geary Street Family Practice	4/27/2021 8:03 AM
Medicaid Billing	NPI: State	Update	Recertification		OR	9/8/2020 4:23 PM
Medicaid Billing	NPI: State	Update	Recertification		OR	9/8/2020 4:23 PM
Medicaid Billing	NPI: State	Update	Recertification		OR	9/8/2020 4:23 PM
Details	Last Recertification Date	Update	Recertification	9/3/2019 3:58:36 PM	9/8/2020 4:23:03 PM	9/8/2020 4:23 PM
Addresses	Billing Address	Update	Change Request	SAMARITAN ALBANY GENERAL HOSPITAL 1046 6th Ave SW Albany, OR 97321	Samaritan Health Services, Inc. PO BOX 3000 Corvallis, OR 97339	8/6/2020 7:09 PM
Contacts	Primary Contact	Update	Change Request	Reher, Penny Chief Pharmacy Officer Good Samaritan Regional Medical Center 5417686177	Douglas, Joy R Rx data Coordinator - 340B Contract Pharmacy Samaritan Health Services 5417686867	8/6/2020 7:09 PM
Addresses	Billing Address	Insert	Change Request		SAMARITAN ALBANY GENERAL HOSPITAL 1046 6th Ave SW Albany, OR 97321	4/22/2020 4:55 PM
Addresses	Shipping Address	Insert	Change Request		SAMARITAN ALBANY GENERAL HOSPITAL 1046 6th Ave SW Albany, OR 97321	4/22/2020 4:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/11/2020 12:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		25527	3/11/2020 12:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	3/11/2020 12:03 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 5:58:55 PM	9/3/2019 3:58:36 PM	9/3/2019 3:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/23/2018 2:23 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500651474	12/23/2018 2:23 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	12/23/2018 2:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/23/2018 2:23 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500673023	12/23/2018 2:23 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	12/23/2018 2:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1972879518	12/23/2018 2:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558776047	12/23/2018 2:23 PM
Details	Last Recertification Date	Update	Recertification	11/17/2017 6:27:22 PM	8/28/2018 5:58:55 PM	8/28/2018 5:58 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	11/17/2017 6:27:22 PM	11/17/2017 6:27 PM
Contacts	Authorizing Official	Update		SMITH, DANIEL B. VP FINANCE/CFO 5417685390	SMITH, DANIEL B. VP FINANCE/CFO Samaritan Albany General Hospital 5417685390	10/23/2017 4:20 PM
Contacts	Primary Contact	Update		Reher, Penny Chief Pharmacy Officer 5417686177	Reher, Penny Chief Pharmacy Officer Good Samaritan Regional Medical Center 5417686177	10/9/2017 2:48 PM
Contacts	Signed By	Update		Reher, Penny Chief Pharmacy Officer 5417686177	Reher, Penny Chief Pharmacy Officer Good Samaritan Regional Medical Center 5417686177	10/9/2017 2:48 PM
Contacts	Primary Contact	Insert			Reher, Penny Chief Pharmacy Officer 5417686177	7/28/2017 6:33 PM
Contacts	Signed By	Insert			Reher, Penny Chief Pharmacy Officer 5417686177	7/28/2017 6:33 PM
Contacts	Authorizing Official	Insert			SMITH, DANIEL B. VP FINANCE/CFO 5417685390	7/28/2017 6:15 PM
Addresses	Main Address	Insert			1700 Geary Street SE Albany, OR 97321	7/28/2017 6:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/19/2017 5:23 PM
Medicaid Billing	Medicaid: Number	Insert			292	7/19/2017 5:23 PM
Medicaid Billing	Medicaid: State	Insert			OR	7/19/2017 5:23 PM
Medicaid Billing	NPI: Number	Insert			1154372340	7/19/2017 5:23 PM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 8:05 PM
Details	Last Recertification Date	Update		8/27/2014 12:00:00 AM	8/31/2015 12:00:00 AM	8/31/2015 4:29 PM
Details	Last Recertification Date	Update		9/9/2013 6:35:14 AM	8/27/2014 12:00:00 AM	8/27/2014 1:05 PM
Details	Last Recertification Date	Update			9/9/2013 6:35:14 AM	9/9/2013 6:35 AM
Details	340B ID	Update		IS-AP-DSH380022C	DSH380022C	10/18/2012 1:34 PM
Dates	Participating Approval Date	Update			10/18/2012 12:00:00 AM	10/18/2012 1:34 PM
Details	State	Update		Pending	Active	10/18/2012 1:34 PM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	10/18/2012 1:34 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-AP-DSH380022C	10/15/2012 11:05 AM
Details	Last Recertification Date	Insert				10/3/2012 2:51 PM
Details	Grant Number	Insert				10/3/2012 2:51 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/3/2012 2:51 PM
Details	Is Authorizing Official EHB Data	Insert				10/3/2012 2:51 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/3/2012 2:51 PM
Details	Medicare Provider Number	Insert			380022	10/3/2012 2:51 PM
Details	Entity Name	Insert			SAMARITAN ALBANY GENERAL HOSPITAL	10/3/2012 2:51 PM
Details	Program Code	Insert			DSH	10/3/2012 2:51 PM
Details	Entity Subname	Insert			SAGH Geary Street Family Pracice	10/3/2012 2:51 PM
Dates	Participating Approval Date	Insert				10/3/2012 2:51 PM
Details	State	Insert			Pending	10/3/2012 2:51 PM
Dates	Registration Date	Insert			10/3/2012 12:00:00 AM	10/3/2012 2:51 PM
Dates	Signed By Date	Insert			10/3/2012 12:00:00 AM	10/3/2012 2:51 PM
Dates	Start Date	Insert				10/3/2012 2:51 PM
Terminations	Termination Comments	Insert				10/3/2012 2:51 PM
Terminations	Termination Date	Insert				10/3/2012 2:51 PM
Terminations	Termination Effective Date	Insert				10/3/2012 2:51 PM
Terminations	Termination Reason	Insert				10/3/2012 2:51 PM