Covered Entity Details

DSH500050D PeaceHealth Southwest Medical Center (Active) - information as of 4/25/2025 8:32:41 PM

Main Details

Name

PeaceHealth Southwest Medical Center

Subdivision Name

Family Medicine of Southwest Washington

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500050D

Medicare Provider Number

500050

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2013

Participating Start Date

7/1/2013

Participating Approval Date

5/17/2013

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

PeaceHealth, Columbia Network
Tracey Fernandez, CFO
(360) 514-3548

Primary Contact

PeaceHealth
Adriane Kindell, 340B Program Supervisor
(360) 414-2137

Addresses

Street Address

100 E 33rd Street
Suite 100
Vancouver, WA 98663

Billing Address

PeaceHealth
1115 SE 164th Ave
Ste. 332
Vancouver, WA 98683

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
WA	3304409	1134178999
OR	185397	1134178999

Shipping Addresses

Shipping Address 1

Southwest Washington Medical Center
600 NE 92nd Ave
Vancouver, WA 98664

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
DSH500050C	Child	DSH	PeaceHealth Southwest Medical Center	Heart & Vascular Clinic	2312 NE 129th Street	Vancouver	WA	Active
DSH500050D	Child	DSH	PeaceHealth Southwest Medical Center	Family Medicine of Southwest Washington	100 E 33rd Street	Vancouver	WA	Active
DSH500050E	Child	DSH	PeaceHealth Southwest Medical Center	PHSW Regional Cancer Center Infusion Services	505 NE 87th Avenue	Vancouver	WA	Active
DSH500050F	Child	DSH	PeaceHealth Southwest Medical Center	Memorial Health Center	3400 Main Street	Vancouver	WA	Terminated
DSH500050G	Child	DSH	PeaceHealth Southwest Medical Center	Ray Hickey Hospice House	2112 East Mill Plain Boulevard	Vancouver	WA	Terminated
DSH500050H	Child	DSH	PeaceHealth Southwest Medical Center	Southwest Heart & Vascular Clinic	200 NE Mother Joseph Place	Vancouver	WA	Active
DSH500050J	Child	DSH	PeaceHealth Southwest Medical Center	Diabetes & Endocrinology Clinic	2312 NE 129th St	Vancouver	WA	Active
DSH500050K	Child	DSH	PeaceHealth Southwest Medical Center	Southwest Outpatient Rehab Therapies	200 NE Mother Joseph Place	Vancouver	WA	Active
DSH500050L	Child	DSH	PeaceHealth Southwest Medical Center	PEACEHEALTH SOUTHWEST MEDICAL CENTER / Wound Healing Center	8716 E MILL PLAIN BLVD	VANCOUVER	WA	Active
DSH500050M	Child	DSH	PeaceHealth Southwest Medical Center	PHSW Interventional Pain Clinic - Pain Management	2312 NE 129th Street	Vancouver	WA	Active
DSH500050N	Child	DSH	PeaceHealth Southwest Medical Center	PHMG Hematology & Oncology Center - Medical Oncology	505 NE 87th Ave	Vancouver	WA	Active
DSH500050P	Child	DSH	PeaceHealth Southwest Medical Center	Physical Medicine & Rehabilitation - Physical Medicine & Rehab	2312 NE 129th Street	Vancouver	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 12:44:27 PM	8/14/2024 3:59:18 PM	8/14/2024 3:59 PM
Contacts	Authorizing Official	Update	Change Request	Gregory, Sean Chief Executive PeaceHealth Columbia Network 3605142082	Fernandez, Tracey CFO PeaceHealth, Columbia Network 3605143548	12/11/2023 8:26 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 2:48:07 PM	8/16/2023 12:44:27 PM	8/16/2023 12:44 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 12:41:06 PM	8/24/2022 2:48:07 PM	8/24/2022 2:48 PM
Contacts	Authorizing Official	Update	Profile Change Request	Gregory, Sean Chief Executive PeaceHealth Southwest Medical Center 3605142082	Gregory, Sean Chief Executive PeaceHealth Columbia Network 3605142082	6/21/2022 6:22 AM
Contacts	Primary Contact	Update	Profile Change Request	Kindell, Adriane 340B Program Specialist PeaceHealth 3604142137	Kindell, Adriane 340B Program Supervisor PeaceHealth 3604142137	1/12/2022 4:04 PM
Contacts	Primary Contact	Update	Profile Change Request	Hall, Adriane 340B Program Specialist PeaceHealth 3604142137	Kindell, Adriane 340B Program Specialist PeaceHealth 3604142137	11/9/2021 11:11 AM
Details	Last Recertification Date	Update	Recertification	8/24/2020 12:47:13 PM	8/16/2021 12:41:06 PM	8/16/2021 12:41 PM
Addresses	Billing Address	Update	Recertification	PeaceHealth 1115 SE 164th Ave Vancouver, WA 98683	PeaceHealth 1115 SE 164th Ave Ste. 332 Vancouver, WA 98683	8/24/2020 12:47 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	500609120 (OR)		8/24/2020 12:47 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1134178999	8/24/2020 12:47 PM
Medicaid Billing	NPI: State	Insert	Recertification		OR	8/24/2020 12:47 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1134178999	8/24/2020 12:47 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	8/24/2020 12:47 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1134178999 ( )		8/24/2020 12:47 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 1:35:49 PM	8/24/2020 12:47:13 PM	8/24/2020 12:47 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 5:08:23 PM	8/20/2019 1:35:49 PM	8/20/2019 1:35 PM
Addresses	Shipping Address	Insert	Recertification		Southwest Washington Medical Center 600 NE 92nd Ave Vancouver, WA 98664	8/22/2018 5:08 PM
Addresses	Billing Address	Update	Recertification	PeaceHealth Southwest Medical Center 600 NE 92nd Avenue PO Box 1600 Vancouver, WA 98664	PeaceHealth 1115 SE 164th Ave Vancouver, WA 98683	8/22/2018 5:08 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 6:53:49 PM	8/22/2018 5:08:23 PM	8/22/2018 5:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/11/2018 4:23 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3304409	6/11/2018 4:23 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	6/11/2018 4:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/11/2018 4:23 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500609120	6/11/2018 4:23 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/11/2018 4:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/11/2018 4:23 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		185397	6/11/2018 4:23 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/11/2018 4:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1134178999	6/11/2018 4:23 PM
Contacts	Primary Contact	Update	Change Request	Tamis, Vicki DIRECTOR, PHARMACY PeaceHealth 3604147821	Hall, Adriane 340B Program Specialist PeaceHealth 3604142137	5/4/2018 6:54 PM
Contacts	Authorizing Official	Update	AO Change Request	Benfield, Ron Chief Financial Officer PeaceHealth 3605142002	Gregory, Sean Chief Executive PeaceHealth Southwest Medical Center 3605142082	5/2/2018 7:16 AM
Contacts	Authorizing Official	Update	Change Request	Gregory, Sean Chief Executive PeaceHealth Southwest Medical Center 3605142082	Benfield, Ron Chief Financial Officer PeaceHealth 3605142002	12/18/2017 7:14 AM
Details	Last Recertification Date	Update	Recertification	8/25/2016 12:00:00 AM	11/8/2017 6:53:49 PM	11/8/2017 6:53 PM
Contacts	Authorizing Official	Update		Gregory, Sean Chief Executive 3605142082	Gregory, Sean Chief Executive PeaceHealth Southwest Medical Center 3605142082	9/29/2017 4:13 PM
Contacts	Primary Contact	Update		Tamis, Vicki DIRECTOR, PHARMACY 3604147821	Tamis, Vicki DIRECTOR, PHARMACY PeaceHealth 3604147821	9/25/2017 7:13 PM
Contacts	Authorizing Official	Update		Baciarelli, Renato V. SVP, Operations & System Services 3607291117	Gregory, Sean Chief Executive 3605142082	9/11/2017 3:29 PM
Contacts	Primary Contact	Insert			Tamis, Vicki DIRECTOR, PHARMACY 3604147821	8/11/2017 9:31 PM
Contacts	Authorizing Official	Insert			Baciarelli, Renato V. SVP, Operations & System Services 3607291117	4/17/2017 7:07 PM
Contacts	Signed By	Insert			Haywood, Thomas Regional Chief Financial Officer 3605143103	11/21/2016 8:44 AM
Addresses	Main Address	Insert			100 E 33rd Street Suite 100 Vancouver, WA 98663	10/25/2016 12:46 PM
Addresses	Billing Address	Insert			PeaceHealth Southwest Medical Center 600 NE 92nd Avenue PO Box 1600 Vancouver, WA 98664	10/25/2016 12:46 PM
Details	Last Recertification Date	Update		9/4/2015 12:00:00 AM	8/25/2016 12:00:00 AM	8/25/2016 12:45 PM
Details	Last Recertification Date	Update		8/15/2014 12:00:00 AM	9/4/2015 12:00:00 AM	9/4/2015 7:39 AM
Details	Last Recertification Date	Update		8/23/2013 4:17:49 PM	8/15/2014 12:00:00 AM	8/15/2014 1:30 PM
Details	Last Recertification Date	Update			8/23/2013 4:17:49 PM	8/23/2013 4:17 PM
Details	340B ID	Update		ISAPDSH500050D	DSH500050D	5/17/2013 11:05 AM
Dates	Participating Approval Date	Update			5/17/2013 12:00:00 AM	5/17/2013 11:05 AM
Details	State	Update		Pending	Active	5/17/2013 11:05 AM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	5/17/2013 11:05 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISAPDSH500050D	4/19/2013 2:04 PM
Details	Last Recertification Date	Insert				4/12/2013 6:01 PM
Details	Grant Number	Insert				4/12/2013 6:01 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/12/2013 6:01 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2013 6:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2013 6:01 PM
Details	Medicare Provider Number	Insert			500050	4/12/2013 6:01 PM
Details	Entity Name	Insert			PeaceHealth Southwest Medical Center	4/12/2013 6:01 PM
Details	Program Code	Insert			DSH	4/12/2013 6:01 PM
Details	Entity Subname	Insert			Family Medicine of Southwest Washington	4/12/2013 6:01 PM
Dates	Participating Approval Date	Insert				4/12/2013 6:01 PM
Details	State	Insert			Pending	4/12/2013 6:01 PM
Dates	Registration Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 6:01 PM
Dates	Signed By Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 6:01 PM
Dates	Start Date	Insert				4/12/2013 6:01 PM
Terminations	Termination Comments	Insert				4/12/2013 6:01 PM
Terminations	Termination Date	Insert				4/12/2013 6:01 PM
Terminations	Termination Effective Date	Insert				4/12/2013 6:01 PM
Terminations	Termination Reason	Insert				4/12/2013 6:01 PM