Covered Entity Details

DSH380051K Salem Health (Terminated) - information as of 5/14/2025 10:59:04 PM

Main Details

Name

Salem Health

Subdivision Name

SH GYN Oncology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH380051K

Medicare Provider Number

380051

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/15/2013

Participating Start Date

7/1/2013

Participating Approval Date

5/15/2013

Last Recertification Date

9/4/2018

Termination Date
Termination Reason

10/1/2019
Business decision by the Covered Entity

Contacts

Authorizing Official

Salem Health Hospitals and Clinics
Josh Free, Chief Pharmacy Officer
(503) 814-2773

Primary Contact

Salem Health
Mishele Dufour, Pharmacy Analyst II
(503) 814-2770

Addresses

Street Address

890 Oak St
Bldg C
Salem, OR 97301

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?
Yes

State	Medicaid Number	NPI Number
OR	194001,213042
		1265431829,1285774257

Shipping Addresses

Same as Street Address

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
DSH380051A	Child	DSH	Salem Hospital	Comprehensive Pain Center	280 Liberty St. SE #320	Salem	OR	Terminated
DSH380051B	Child	DSH	Salem Health	Salem Health Medical Clinic - Keizer	550 Dietz Ave. NE	Keizer	OR	Terminated
DSH380051C	Child	DSH	Salem Hospital	Regional Rehabilitation Center	Building M	Salem	OR	Terminated
DSH380051D	Child	DSH	Salem Health	Salem Health Urgent Care	1002 Bellevue St. SE	Salem	OR	Terminated
DSH380051E	Child	DSH	Salem Hospital	WHP Midwives	875 Oak Street SE	Salem	OR	Terminated
DSH380051F	Child	DSH	Salem Health	Salem Health Medical Clinic - Edgewater	1049 Edgewater St. NW, Suite 150	Salem	OR	Terminated
DSH380051G	Child	DSH	Salem Health	Salem Health Medical Clinic - 12th St	966 12th Street SE	Salem	OR	Terminated
DSH380051H	Child	DSH	Salem Health	Salem Health Medical Clinic - River Road South	2925 River Road South	Salem	OR	Terminated
DSH380051J	Child	DSH	Salem Health	Salem Health Obstetrics and Gynecology	890 Oak St	Salem	OR	Terminated
DSH380051K	Child	DSH	Salem Health	SH GYN Oncology	890 Oak St	Salem	OR	Terminated
DSH380051L	Child	DSH	Salem Health	SALEM HOSPITAL - RRS Medication Management Clinic	2925 RIVER RD S	SALEM	OR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Parr, James Chief Financial Officer Salem Health 5038142841	Free, Josh Chief Pharmacy Officer Salem Health Hospitals and Clinics 5038142773	12/30/2019 1:26 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		4/1/2019 12:00:00 AM	8/27/2019 8:05 AM
Details	State	Update	Recertification	Active	To Be Terminated	8/27/2019 8:05 AM
Terminations	Termination Date	Update	Recertification		10/1/2019 12:00:00 AM	8/27/2019 8:05 AM
Terminations	Termination Effective Date	Update	Recertification		7/1/2019 12:00:00 AM	8/27/2019 8:05 AM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	8/27/2019 8:05 AM
Contacts	Primary Contact	Update	Change Request	Schnabel, Joseph Director of Pharmacy Salem Health 5038142773	Dufour, Mishele Pharmacy Analyst II Salem Health 5038142770	1/23/2019 11:13 AM
Contacts	Primary Contact	Update	Profile Change Request	Schnabel, Joseph Director of Pharmacy Salem Health 5035615165	Schnabel, Joseph Director of Pharmacy Salem Health 5038142773	10/9/2018 12:08 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 12:05:13 PM	9/4/2018 12:11:55 PM	9/4/2018 12:11 PM
Contacts	Authorizing Official	Update	Profile Change Request	Parr, James Chief Financial Officer Salem Health 5035615527	Parr, James Chief Financial Officer Salem Health 5038142841	4/9/2018 5:39 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	12/4/2017 12:05:13 PM	12/4/2017 12:05 PM
Contacts	Authorizing Official	Update		Parr, James Chief Financial Officer 5035615527	Parr, James Chief Financial Officer Salem Health 5035615527	10/3/2017 1:39 PM
Contacts	Primary Contact	Update		Schnabel, Joseph Director of Pharmacy 5035615165	Schnabel, Joseph Director of Pharmacy Salem Health 5035615165	9/20/2017 5:54 PM
Contacts	Authorizing Official	Insert			Parr, James Chief Financial Officer 5035615527	8/11/2017 11:42 AM
Contacts	Primary Contact	Insert			Schnabel, Joseph Director of Pharmacy 5035615165	8/11/2017 11:42 AM
Contacts	Signed By	Insert			Crane, Aaron CFO 5035615652	8/11/2017 11:42 AM
Addresses	Main Address	Insert			890 Oak St Bldg C Salem, OR 97301	8/11/2017 7:50 AM
Details	Entity Name	Update		Salem Hospital	Salem Health	8/11/2017 7:49 AM
Details	Entity Subname	Update		Gynecologic Oncology Clinic	SH GYN Oncology	8/11/2017 7:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/31/2016 9:39 AM
Medicaid Billing	Medicaid: Number	Insert			194001	8/31/2016 9:39 AM
Medicaid Billing	Medicaid: State	Insert			OR	8/31/2016 9:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/31/2016 9:39 AM
Medicaid Billing	Medicaid: Number	Insert			213042	8/31/2016 9:39 AM
Medicaid Billing	Medicaid: State	Insert			OR	8/31/2016 9:39 AM
Medicaid Billing	NPI: Number	Insert			1265431829	8/31/2016 9:39 AM
Medicaid Billing	NPI: Number	Insert			1285774257	8/31/2016 9:39 AM
Details	Last Recertification Date	Update		9/4/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/31/2016 9:39 AM
Details	Last Recertification Date	Update		8/20/2014 12:00:00 AM	9/4/2015 12:00:00 AM	9/4/2015 7:43 AM
Details	Last Recertification Date	Update		9/11/2013 12:06:02 PM	8/20/2014 12:00:00 AM	8/20/2014 2:07 PM
Details	Last Recertification Date	Update			9/11/2013 12:06:02 PM	9/11/2013 12:06 PM
Details	340B ID	Update		ISDMDSH380051K	DSH380051K	5/15/2013 6:06 PM
Dates	Participating Approval Date	Update			5/15/2013 12:00:00 AM	5/15/2013 6:06 PM
Details	State	Update		Pending	Active	5/15/2013 6:06 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	5/15/2013 6:06 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISDMDSH380051K	4/29/2013 2:20 PM
Details	Last Recertification Date	Insert				4/15/2013 12:57 PM
Details	Grant Number	Insert				4/15/2013 12:57 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/15/2013 12:57 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2013 12:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2013 12:57 PM
Details	Medicare Provider Number	Insert			380051	4/15/2013 12:57 PM
Details	Entity Name	Insert			Salem Hospital	4/15/2013 12:57 PM
Details	Program Code	Insert			DSH	4/15/2013 12:57 PM
Details	Entity Subname	Insert			Gynecologic Oncology Clinic	4/15/2013 12:57 PM
Dates	Participating Approval Date	Insert				4/15/2013 12:57 PM
Details	State	Insert			Pending	4/15/2013 12:57 PM
Dates	Registration Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 12:57 PM
Dates	Signed By Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 12:57 PM
Dates	Start Date	Insert				4/15/2013 12:57 PM
Terminations	Termination Comments	Insert				4/15/2013 12:57 PM
Terminations	Termination Date	Insert				4/15/2013 12:57 PM
Terminations	Termination Effective Date	Insert				4/15/2013 12:57 PM
Terminations	Termination Reason	Insert				4/15/2013 12:57 PM