Covered Entity Details

CAH051316-00 Fairchild Medical Center (Active) - information as of 5/3/2025 11:30:37 PM

Main Details

Name

Fairchild Medical Center

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH051316-00

Medicare Provider Number

051316

Additional Details

Current Program Status

Active

Registration Date

4/15/2013

Participating Start Date

7/1/2013

Participating Approval Date

4/23/2013

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Fairchild Medical Center
Kelly Martin, CFO
(530) 841-6235

Primary Contact

Fairchild Medical Center
Cheryl Lynn Freckman, Financial Systems Manager
(530) 841-6306

Addresses

Street Address

444 Bruce St
Yreka, CA 96097

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?
No

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	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/14/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/14/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/14/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/14/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/14/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/14/2023	07/01/2023		07/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/14/2023	07/01/2023		07/01/2023
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/14/2023	07/01/2023		07/01/2023
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/14/2023	07/01/2023		07/01/2023
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/14/2023	07/01/2023		07/01/2023
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/14/2023	07/01/2023		07/01/2023
Contract Detail	KJL CONSULTANTS, INC	DBA- LUKE'S YREKA DRUG	829 S MAIN ST	YREKA	CA	96097	07/01/2013	10/01/2013	07/11/2019	07/11/2019
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	04/14/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/14/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/14/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	04/14/2023	07/01/2023		07/01/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/14/2023	07/01/2023		07/01/2023
Contract Detail	RALEY'S PHARMACY #247	1842 FORT JONES STREET		YREKA	CA	96097	07/11/2019	10/01/2019		10/01/2019
Contract Detail	SISKIYOU PHARMACY SERVICES	DBA MEDICAL CENTER PHARMACY	742 S. MAIN STREET	YREKA	CA	96097	07/01/2013	10/01/2013	07/11/2019	07/11/2019
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6100	3095 MCMURRAY DRIVE	ANDERSON	CA	96007	05/09/2013	07/01/2013	05/08/2015	05/06/2015
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6103	310 WEST LAKE STREET	MOUNT SHASTA	CA	96067	05/09/2013	07/01/2013		05/09/2013
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6104	807 SOUTH MAIN STREET	YREKA	CA	96097	05/09/2013	07/01/2013		05/09/2013
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/14/2023	07/01/2023		07/01/2023
Contract Detail	WAL-MART PHARMACY 10-1630	1906 FORT JONES ROAD		YREKA	CA	96097	01/14/2014	04/01/2014		01/14/2014
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	04/14/2023	07/01/2023		07/01/2023
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/14/2023	07/01/2023		07/01/2023
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/14/2023	07/01/2023		07/01/2023
Contract Detail	YREKA PHARMACY	748 S. MAIN ST.		YREKA	CA	96097	10/15/2019	01/01/2020		01/01/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH051316-01	Child	CAH	Fairchild Medical Center	Scott Valley Rural Health Clinic	155 Diggles St	Etna	CA	Active
CAH051316-02	Child	CAH	Fairchild Medical Center	Fairchild Medical Clinic	475 Bruce St	Yreka	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Recertification	1093892275 (CA)		9/4/2024 12:26 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1093892275 (CA)		9/4/2024 12:26 PM
Details	Last Recertification Date	Update	Recertification	8/25/2023 7:35:01 AM	9/4/2024 12:26:12 PM	9/4/2024 12:26 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 12:46:46 PM	8/25/2023 7:35:01 AM	8/25/2023 7:35 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 10:46:52 AM	8/29/2022 12:46:46 PM	8/29/2022 12:46 PM
Details	Last Recertification Date	Update	Recertification	9/3/2020 7:56:09 PM	9/9/2021 10:46:52 AM	9/9/2021 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2020 7:56 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1093892275	9/3/2020 7:56 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/3/2020 7:56 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/3/2020 7:56 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 6:32:49 AM	9/3/2020 7:56:09 PM	9/3/2020 7:56 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 11:00:31 AM	8/26/2019 6:32:49 AM	8/26/2019 6:32 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 7:41:12 AM	8/24/2018 11:00:31 AM	8/24/2018 11:00 AM
Contacts	Primary Contact	Update	Recertification	Martin, Kelly CFO 5308416235	Freckman, Cheryl Lynn Financial Systems Manager Fairchild Medical Center 5308416306	11/15/2017 7:41 AM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/15/2017 7:41:12 AM	11/15/2017 7:41 AM
Contacts	Authorizing Official	Update		Martin, Kelly CFO 5308416235	Martin, Kelly CFO Fairchild Medical Center 5308416235	10/27/2017 1:13 PM
Contacts	Signed By	Update		Martin, Kelly CFO 5308416235	Martin, Kelly CFO Fairchild Medical Center 5308416235	10/27/2017 1:13 PM
Addresses	Main Address	Insert			444 Bruce St Yreka, CA 96097	8/10/2016 10:08 AM
Contacts	Authorizing Official	Insert			Martin, Kelly CFO 5308416235	8/10/2016 10:08 AM
Contacts	Primary Contact	Insert			Martin, Kelly CFO 5308416235	8/10/2016 10:08 AM
Contacts	Signed By	Insert			Martin, Kelly CFO 5308416235	8/10/2016 10:08 AM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 10:08 AM
Details	Last Recertification Date	Update		8/27/2014 12:00:00 AM	8/31/2015 12:00:00 AM	8/31/2015 3:41 PM
Details	Last Recertification Date	Update		9/9/2013 12:56:30 PM	8/27/2014 12:00:00 AM	8/27/2014 12:02 PM
Details	Last Recertification Date	Update			9/9/2013 12:56:30 PM	9/9/2013 12:56 PM
Details	340B ID	Update		ISDMCAH051316-00	CAH051316-00	4/23/2013 12:47 PM
Dates	Participating Approval Date	Update			4/23/2013 12:00:00 AM	4/23/2013 12:47 PM
Details	State	Update		Pending	Active	4/23/2013 12:47 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	4/23/2013 12:47 PM
Details	340B ID	Update		ISDMCAH051316-00A	ISDMCAH051316-00	4/17/2013 1:43 PM
Details	340B ID	Update		A	ISDMCAH051316-00A	4/17/2013 1:42 PM
Details	340B ID	Update		DELETE041713-Duplicate	A	4/17/2013 1:25 PM
Details	State	Update		Rejected	Pending	4/17/2013 1:25 PM
Details	340B ID	Update		ONLINE_REG	DELETE041713-Duplicate	4/17/2013 1:21 PM
Details	State	Update		Pending	Rejected	4/17/2013 1:21 PM
Medicaid Billing	NPI: Number	Insert			1093892275	4/15/2013 12:10 PM
Details	Last Recertification Date	Insert				4/15/2013 12:10 PM
Details	Grant Number	Insert				4/15/2013 12:10 PM
Details	340B ID	Insert			ONLINE_REG	4/15/2013 12:10 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2013 12:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2013 12:10 PM
Details	Medicare Provider Number	Insert			051316	4/15/2013 12:10 PM
Details	Entity Name	Insert			Fairchild Medical Center	4/15/2013 12:10 PM
Details	Program Code	Insert			CAH	4/15/2013 12:10 PM
Details	Entity Subname	Insert				4/15/2013 12:10 PM
Dates	Participating Approval Date	Insert				4/15/2013 12:10 PM
Details	State	Insert			Pending	4/15/2013 12:10 PM
Dates	Registration Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 12:10 PM
Dates	Signed By Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 12:10 PM
Dates	Start Date	Insert				4/15/2013 12:10 PM
Terminations	Termination Comments	Insert				4/15/2013 12:10 PM
Terminations	Termination Date	Insert				4/15/2013 12:10 PM
Terminations	Termination Effective Date	Insert				4/15/2013 12:10 PM
Terminations	Termination Reason	Insert				4/15/2013 12:10 PM