Covered Entity Details

DSH050006D St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital (Terminated) - information as of 5/14/2025 10:56:46 PM

Main Details

Name

St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital

Subdivision Name

GI Lab

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH050006D

Medicare Provider Number

050006

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/13/2014

Participating Start Date

4/1/2014

Participating Approval Date

3/12/2014

Last Recertification Date

8/20/2019

Termination Date
Termination Reason

7/1/2020
Business decision by the Covered Entity

Contacts

Authorizing Official

St. Joseph Health
Kevin Klockenga, CEO
(707) 522-1520

Primary Contact

St.Joseph Health
Virginia Elizabeth Schuchard, NorCal Region 340B Program Manager
(507) 271-8661

Addresses

Street Address

2200 Harrison Ave.
Eureka, CA 95501

Billing Address

St. Joseph Hospital
2700 Dolbeer Street
Eureka, CA 95501

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	ZZR400006F
		1891900635

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
DSH050006B	Child	DSH	St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital	North Coast Pain Center	2705 Harris Street	Eureka	CA	Active
DSH050006C	Child	DSH	St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital	Outpatient Imaging Center	2330 Buhne Street	Eureka	CA	Terminated
DSH050006D	Child	DSH	St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital	GI Lab	2200 Harrison Ave.	Eureka	CA	Terminated
DSH050006E	Child	DSH	St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital	AMBULATORY INFUSION PROGRAM	2612 HARRISON AVE	EUREKA	CA	Terminated
DSH050006F	Child	DSH	St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital	St. Joseph Hospital - Eureka - Pharmacotherapy	2752 Harrison Ave	Eureka	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		4/23/2020 12:00:00 AM	4/24/2020 4:18 PM
Details	State	Update	Termination Request	Active	To Be Terminated	4/24/2020 4:18 PM
Terminations	Termination Comments	Update	Termination Request		Entity moved within the four walls of the hospital.	4/24/2020 4:18 PM
Terminations	Termination Date	Update	Termination Request		7/1/2020 12:00:00 AM	4/24/2020 4:18 PM
Terminations	Termination Effective Date	Update	Termination Request		4/23/2020 12:00:00 AM	4/24/2020 4:18 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	4/24/2020 4:18 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 12:59:26 PM	8/20/2019 6:49:04 PM	8/20/2019 6:49 PM
Contacts	Authorizing Official	Update	Profile Change Request	Klockenga, Kevin CEO St. Joseph Health 7045221520	Klockenga, Kevin CEO St. Joseph Health 7075221520	5/23/2019 2:26 PM
Contacts	Primary Contact	Update	Profile Change Request	Schuchard, Virginia Elizabeth Northern California Region 340B Manager St.Joseph Health 5072718661	Schuchard, Virginia Elizabeth NorCal Region 340B Program Manager St.Joseph Health 5072718661	4/8/2019 8:15 PM
Contacts	Primary Contact	Update	Profile Change Request	Schuchard, Virginia Elizabeth 340B Lead Analyst St.Joseph Health 7074458121-6220	Schuchard, Virginia Elizabeth Northern California Region 340B Manager St.Joseph Health 5072718661	4/8/2019 8:12 PM
Contacts	Authorizing Official	Update	Change Request	Iyer, Raju Regional CFO St. Joseph Health 7078068781	Klockenga, Kevin CEO St. Joseph Health 7045221520	10/23/2018 9:48 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 2:08:28 PM	8/16/2018 12:59:26 PM	8/16/2018 12:59 PM
Details	Entity Name	Update	Change Request	ST. JOSEPH HOSPITAL	St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital	7/27/2018 11:08 AM
Contacts	Primary Contact	Update	Change Request	Klakken, Vicky Regional Director 340B Pharmacy Operations St Joseph Health 7072694236	Schuchard, Virginia Elizabeth 340B Lead Analyst St.Joseph Health 7074458121-6220	6/25/2018 7:00 PM
Contacts	Authorizing Official	Update	Change Request	Petrina, Robert CFO St. Josepsh Health 7075255320	Iyer, Raju Regional CFO St. Joseph Health 7078068781	4/19/2018 4:24 PM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/9/2017 2:08:28 PM	11/9/2017 2:08 PM
Contacts	Authorizing Official	Update		Petrina, Robert CFO 7075255320	Petrina, Robert CFO St. Josepsh Health 7075255320	9/27/2017 5:43 PM
Contacts	Primary Contact	Update		Klakken, Vicky Regional Director 340B Pharmacy Operations 7072694236	Klakken, Vicky Regional Director 340B Pharmacy Operations St Joseph Health 7072694236	9/20/2017 2:37 PM
Contacts	Signed By	Insert			Riccioni, Mich CFO 7074458121-7491	6/13/2017 2:07 PM
Contacts	Primary Contact	Update		Clougherty, Kevin Regional Director 340B Pharmacy Operations 7072694236	Klakken, Vicky Regional Director 340B Pharmacy Operations 7072694236	6/13/2017 2:07 PM
Contacts	Authorizing Official	Insert			Petrina, Robert CFO 7075255320	6/13/2017 8:07 AM
Addresses	Main Address	Insert			2200 Harrison Ave. Eureka, CA 95501	6/13/2017 8:00 AM
Addresses	Billing Address	Insert			St. Joseph Hospital 2700 Dolbeer Street Eureka, CA 95501	6/13/2017 8:00 AM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 3:47 PM
Contacts	Primary Contact	Insert			Clougherty, Kevin Regional Director 340B Pharmacy Operations 7072694236	8/19/2016 10:33 AM
Details	Last Recertification Date	Update		8/6/2014 12:00:00 AM	8/6/2015 12:00:00 AM	8/6/2015 6:15 PM
Details	Last Recertification Date	Update			8/6/2014 12:00:00 AM	8/6/2014 3:32 PM
Dates	Participating Approval Date	Update			3/12/2014 12:00:00 AM	3/12/2014 12:06 AM
Details	State	Update		Pending	Active	3/12/2014 12:06 AM
Dates	Start Date	Update			4/1/2014 12:00:00 AM	3/12/2014 12:06 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH050006D	2/25/2014 5:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/13/2014 12:49 PM
Medicaid Billing	Medicaid: Number	Insert			ZZR400006F	1/13/2014 12:49 PM
Medicaid Billing	Medicaid: State	Insert			CA	1/13/2014 12:49 PM
Medicaid Billing	NPI: Number	Insert			1891900635	1/13/2014 12:49 PM
Details	Last Recertification Date	Insert				1/13/2014 12:49 PM
Details	Grant Number	Insert				1/13/2014 12:49 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/13/2014 12:49 PM
Details	Is Authorizing Official EHB Data	Insert				1/13/2014 12:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/13/2014 12:49 PM
Details	Medicare Provider Number	Insert			050006	1/13/2014 12:49 PM
Details	Entity Name	Insert			ST. JOSEPH HOSPITAL	1/13/2014 12:49 PM
Details	Program Code	Insert			DSH	1/13/2014 12:49 PM
Details	Entity Subname	Insert			GI Lab	1/13/2014 12:49 PM
Dates	Participating Approval Date	Insert				1/13/2014 12:49 PM
Details	State	Insert			Pending	1/13/2014 12:49 PM
Dates	Registration Date	Insert			1/13/2014 12:00:00 AM	1/13/2014 12:49 PM
Dates	Signed By Date	Insert			1/13/2014 12:00:00 AM	1/13/2014 12:49 PM
Dates	Start Date	Insert				1/13/2014 12:49 PM
Terminations	Termination Comments	Insert				1/13/2014 12:49 PM
Terminations	Termination Date	Insert				1/13/2014 12:49 PM
Terminations	Termination Effective Date	Insert				1/13/2014 12:49 PM
Terminations	Termination Reason	Insert				1/13/2014 12:49 PM