Covered Entity Details

CAH051332-01 Mark Twain Medical Center (Active) - information as of 5/11/2025 11:43:39 PM

Main Details

Name

Mark Twain Medical Center

Subdivision Name

COPPEROPOLIS FAMILY MEDICAL CENTER

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH051332-01

Medicare Provider Number

051332

Outpatient Facility Provider Number

058548

Additional Details

Current Program Status

Active

Registration Date

1/14/2013

Participating Start Date

4/1/2013

Participating Approval Date

1/14/2013

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Mark Twain Medical Center
Doug Archer, President/CEO
(209) 754-5916

Primary Contact

Mark Twain Medical Center
Jill Ortiz, Director of Pharmacy
(209) 754-2464

Addresses

Street Address

430 Sawmill Creek Rd. Unit 6 Suite A
Copperopolis, CA 95228-9424

Billing Address

Dignity Health AP SAC
3400 Data Drive
Rancho Cordova, CA 95670

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	ZZR00366G	1588725196

Shipping Addresses

Shipping Address 1

Mark Twain Medical Center
768 Mountain Ranch Road
San Andreas, CA 95249

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
CAH051332-01	Child	CAH	Mark Twain Medical Center	COPPEROPOLIS FAMILY MEDICAL CENTER	430 Sawmill Creek Rd. Unit 6 Suite A	Copperopolis	CA	Active
CAH051332-02	Child	CAH	Mark Twain Medical Center	VALLEY SPRINGS FAMILY MEDICAL CLINIC	1919 Vista Del Lago Dr	Valley Springs	CA	Terminated
CAH051332-03	Child	CAH	Mark Twain Medical Center	James Dalton Medical Office	590 Stanislaus Avenue	Angels Camp	CA	Active
CAH051332-04	Child	CAH	Mark Twain Medical Center	ARNOLD MEDICAL CLINIC	2182 Highway 4, Ste A-100	Arnold	CA	Active
CAH051332-05	Child	CAH	Mark Twain Medical Center	San Andreas Medical Clinic	702 Mountain Ranch Rd.	San Andreas	CA	Active
CAH051332-06	Child	CAH	Mark Twain Medical Center	Cancer Center	700 Mountain Ranch Road	San Andreas	CA	Active
CAH051332-07	Child	CAH	Mark Twain Medical Center	Infusion Center	700 Mountain Ranch Road	San Andreas	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Archer, Doug Patrick President/CEO Mark Twain Medical Center 2097545916	Archer, Doug President/CEO Mark Twain Medical Center 2097545916	1/13/2025 3:00 PM
Contacts	Authorizing Official	Update	Profile Change Request	Archer, Doug Patrick President/CEO Mark Twain Medical Center 2097542515	Archer, Doug Patrick President/CEO Mark Twain Medical Center 2097545916	1/6/2025 4:07 PM
Details	Last Recertification Date	Update	Recertification	8/16/2023 6:14:33 PM	8/13/2024 4:29:21 PM	8/13/2024 4:29 PM
Details	Last Recertification Date	Update	Recertification	8/25/2022 1:12:56 PM	8/16/2023 6:14:33 PM	8/16/2023 6:14 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 2:01:59 PM	8/25/2022 1:12:56 PM	8/25/2022 1:12 PM
Addresses	Main Address	Update	Change Request	3505 Spangler Lane, Ste 400 Copperopolis, CA 95228-9424	430 Sawmill Creek Rd. Unit 6 Suite A Copperopolis, CA 95228-9424	9/30/2021 6:23 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 2:37:50 PM	8/23/2021 2:01:59 PM	8/23/2021 2:01 PM
Addresses	Shipping Address	Delete	Change Request	Mark Twain Medical Center 768 Mountain Ranch Road San Andreas, CA 95252		12/15/2020 9:18 AM
Addresses	Shipping Address	Insert	Change Request		Mark Twain Medical Center 768 Mountain Ranch Road San Andreas, CA 95249	12/15/2020 9:18 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/2/2020 2:37 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 8:56:10 PM	9/2/2020 2:37:50 PM	9/2/2020 2:37 PM
Addresses	Shipping Address	Insert	Change Request		Mark Twain Medical Center 768 Mountain Ranch Road San Andreas, CA 95252	2/24/2020 7:59 AM
Addresses	Billing Address	Update	Change Request	Mark Twain St. Joseph's Hospital 768 Mountain Ranch Road San Andreas, CA 95249	Dignity Health AP SAC 3400 Data Drive Rancho Cordova, CA 95670	2/24/2020 7:59 AM
Details	Last Recertification Date	Update	Recertification	8/24/2018 5:17:34 PM	8/27/2019 8:56:10 PM	8/27/2019 8:56 PM
Contacts	Authorizing Official	Update	Change Request	Philipp, Larry CEO Mark Twain Medical Center 2097542515	Archer, Doug Patrick President/CEO Mark Twain Medical Center 2097542515	7/26/2019 6:55 AM
Contacts	Authorizing Official	Update	Change Request	Roberts, Chris CFO Mark Twain Medical Center 2097542614	Philipp, Larry CEO Mark Twain Medical Center 2097542515	1/31/2019 12:06 PM
Details	Last Recertification Date	Update	Recertification	11/6/2017 2:36:40 PM	8/24/2018 5:17:34 PM	8/24/2018 5:17 PM
Details	Entity Name	Update	Recertification	Mark Twain St. Joseph's Hospital	Mark Twain Medical Center	11/7/2017 7:26 AM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/6/2017 2:36:40 PM	11/6/2017 2:36 PM
Contacts	Authorizing Official	Update		Roberts, Chris CFO 2097542614	Roberts, Chris CFO Mark Twain Medical Center 2097542614	10/20/2017 1:17 PM
Contacts	Primary Contact	Update		Ortiz, Jill Director of Pharmacy 2097542464	Ortiz, Jill Director of Pharmacy Mark Twain Medical Center 2097542464	10/19/2017 5:14 PM
Contacts	Primary Contact	Insert			Ortiz, Jill Director of Pharmacy 2097542464	8/22/2016 4:08 PM
Contacts	Authorizing Official	Insert			Roberts, Chris CFO 2097542614	8/22/2016 4:08 PM
Contacts	Signed By	Insert			Marks, Craig Hospital President 2097522515	8/22/2016 4:08 PM
Addresses	Main Address	Insert			3505 Spangler Lane, Ste 400 Copperopolis, CA 95228-9424	8/22/2016 4:08 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 4:08 PM
Addresses	Billing Address	Insert			Mark Twain St. Joseph's Hospital 768 Mountain Ranch Road San Andreas, CA 95249	7/7/2016 9:23 AM
Details	Last Recertification Date	Update		8/14/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 12:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/30/2015 5:53 PM
Medicaid Billing	Medicaid: Number	Insert			ZZR00366G	6/30/2015 5:53 PM
Medicaid Billing	Medicaid: State	Insert			CA	6/30/2015 5:53 PM
Medicaid Billing	NPI: Number	Insert			1588725196	6/30/2015 5:53 PM
Details	Last Recertification Date	Update		9/5/2013 1:52:43 PM	8/14/2014 12:00:00 AM	8/14/2014 6:43 AM
Details	Last Recertification Date	Update			9/5/2013 1:52:43 PM	9/5/2013 1:52 PM
Details	340B ID	Update		ISAPCAH051332-01	CAH051332-01	1/14/2013 4:59 PM
Dates	Participating Approval Date	Update			1/14/2013 12:00:00 AM	1/14/2013 4:59 PM
Details	State	Update		Pending	Active	1/14/2013 4:59 PM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	1/14/2013 4:59 PM
Details	340B ID	Update		AP011314J	ISAPCAH051332-01	1/14/2013 3:26 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	AP011314J	1/14/2013 3:08 PM
Details	Last Recertification Date	Insert				1/14/2013 9:22 AM
Details	Grant Number	Insert				1/14/2013 9:22 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/14/2013 9:22 AM
Details	Is Authorizing Official EHB Data	Insert				1/14/2013 9:22 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/14/2013 9:22 AM
Details	Medicare Provider Number	Insert			051332	1/14/2013 9:22 AM
Details	Entity Name	Insert			Mark Twain St. Joseph's Hospital	1/14/2013 9:22 AM
Details	Program Code	Insert			CAH	1/14/2013 9:22 AM
Details	Entity Subname	Insert			COPPEROPOLIS FAMILY MEDICAL CENTER	1/14/2013 9:22 AM
Dates	Participating Approval Date	Insert				1/14/2013 9:22 AM
Details	State	Insert			Pending	1/14/2013 9:22 AM
Dates	Registration Date	Insert			1/14/2013 12:00:00 AM	1/14/2013 9:22 AM
Dates	Signed By Date	Insert			1/14/2013 12:00:00 AM	1/14/2013 9:22 AM
Dates	Start Date	Insert				1/14/2013 9:22 AM
Terminations	Termination Comments	Insert				1/14/2013 9:22 AM
Terminations	Termination Date	Insert				1/14/2013 9:22 AM
Terminations	Termination Effective Date	Insert				1/14/2013 9:22 AM
Terminations	Termination Reason	Insert				1/14/2013 9:22 AM