Covered Entity Details

CAH501337-03 LOURDES MEDICAL CENTER (Terminated) - information as of 5/14/2025 10:56:32 PM

Main Details

Name

LOURDES MEDICAL CENTER

Subdivision Name

Family Medicine

Type

Critical Access Hospital

Rural

340B ID

CAH501337-03

Medicare Provider Number

501337

Outpatient Facility Provider Number

GAB064

Additional Details

Current Program Status

Terminated

Registration Date

7/14/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/15/2014

Last Recertification Date

11/13/2017

Termination Date
Termination Reason

10/1/2018
For-Profit conversion

Contacts

Authorizing Official

Lourdes Medical Center
FRANK R BECKER, CFO
(509) 546-2282

Primary Contact

Lourdes Medical Center
Tracy Sue Clark, Director of Pharmacy
(509) 546-2298

Addresses

Street Address

7425 Wrigley Drive
Suite 100
Pasco, WA 99301

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
WA	2002146
		1659505840

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
CAH501337-01	Child	CAH	LOURDES MEDICAL CENTER	Lourdes Occupational Health	9915 Sandifur Parkway	Pasco	WA	Terminated
CAH501337-02	Child	CAH	LOURDES MEDICAL CENTER	Pediatrics	7425 Wrigley Drive	Pasco	WA	Terminated
CAH501337-03	Child	CAH	LOURDES MEDICAL CENTER	Family Medicine	7425 Wrigley Drive	Pasco	WA	Terminated
CAH501337-04	Child	CAH	LOURDES MEDICAL CENTER	Women's Health	7425 Wrigley Drive	Pasco	WA	Terminated
CAH501337-05	Child	CAH	LOURDES MEDICAL CENTER	Lourdes West Pasco / Gastroenterology	7425 Wrigley Drive Ste 100	Pasco	WA	Terminated
CAH501337-06	Child	CAH	LOURDES MEDICAL CENTER	Lourdes West Pasco / Surgical and Breast Care Center	7425 Wrigley Drive Ste 204	Pasco	WA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2018 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		8/31/2018 12:00:00 AM	9/12/2018 12:59 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/12/2018 12:59 PM
Terminations	Termination Comments	Update	Recertification		Entity Purchased by RCCH Healthcare Partners	9/12/2018 12:59 PM
Terminations	Termination Date	Update	Recertification		10/1/2018 12:00:00 AM	9/12/2018 12:59 PM
Terminations	Termination Effective Date	Update	Recertification		9/1/2018 12:00:00 AM	9/12/2018 12:59 PM
Terminations	Termination Reason	Update	Recertification		For-Profit conversion	9/12/2018 12:59 PM
Contacts	Primary Contact	Update		Clark, Tracy Director of Pharmacy Lourdes Medical Center 5095462298	Clark, Tracy Sue Director of Pharmacy Lourdes Medical Center 5095462298	1/15/2018 6:52 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/13/2017 1:28:15 PM	11/13/2017 1:28 PM
Contacts	Primary Contact	Update	Recertification	Clark, Tracy Director of Pharmacy 5095462298	Clark, Tracy Director of Pharmacy Lourdes Medical Center 5095462298	11/13/2017 1:26 PM
Contacts	Authorizing Official	Update		BECKER, FRANK CFO 5095462282	BECKER, FRANK R CFO Lourdes Medical Center 5095462282	10/6/2017 1:10 PM
Contacts	Signed By	Update		BECKER, FRANK CFO 5095462282	BECKER, FRANK R CFO Lourdes Medical Center 5095462282	10/6/2017 1:10 PM
Addresses	Main Address	Insert			7425 Wrigley Drive Suite 100 Pasco, WA 99301	9/1/2016 6:32 PM
Contacts	Authorizing Official	Insert			BECKER, FRANK CFO 5095462282	9/1/2016 6:32 PM
Contacts	Signed By	Insert			BECKER, FRANK CFO 5095462282	9/1/2016 6:32 PM
Contacts	Primary Contact	Insert			Clark, Tracy Director of Pharmacy 5095462298	9/1/2016 6:32 PM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/1/2016 6:32 PM
Details	Last Recertification Date	Update			8/14/2015 12:00:00 AM	8/14/2015 6:04 PM
Details	Entity Subname	Update		Lourdes West Pasco Family Medicine / Family Medicine	Family Medicine	12/31/2014 3:51 PM
Details	Entity Subname	Update		Lourdes West Pasco Family Medicine	Lourdes West Pasco Family Medicine / Family Medicine	12/19/2014 2:16 PM
Details	340B ID	Update		DSH501337-03	CAH501337-03	9/15/2014 1:08 PM
Dates	Participating Approval Date	Update			9/15/2014 12:00:00 AM	9/15/2014 1:08 PM
Details	State	Update		Pending	Active	9/15/2014 1:08 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/15/2014 1:08 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45733	DSH501337-03	9/15/2014 10:55 AM
Details	Entity Subname	Update		Lourdes West Pasco	Lourdes West Pasco Family Medicine	9/15/2014 10:27 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_45733	7/14/2014 9:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/14/2014 9:03 PM
Medicaid Billing	Medicaid: Number	Insert			2002146	7/14/2014 9:03 PM
Medicaid Billing	Medicaid: State	Insert			WA	7/14/2014 9:03 PM
Medicaid Billing	NPI: Number	Insert			1659505840	7/14/2014 9:03 PM
Details	Last Recertification Date	Insert				7/14/2014 9:03 PM
Details	Grant Number	Insert				7/14/2014 9:03 PM
Details	340B ID	Insert				7/14/2014 9:03 PM
Details	Is Authorizing Official EHB Data	Insert				7/14/2014 9:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/14/2014 9:03 PM
Details	Medicare Provider Number	Insert			501337	7/14/2014 9:03 PM
Details	Entity Name	Insert			LOURDES MEDICAL CENTER	7/14/2014 9:03 PM
Details	Program Code	Insert			CAH	7/14/2014 9:03 PM
Details	Entity Subname	Insert			Lourdes West Pasco	7/14/2014 9:03 PM
Dates	Participating Approval Date	Insert				7/14/2014 9:03 PM
Details	State	Insert			Pending	7/14/2014 9:03 PM
Dates	Registration Date	Insert			7/14/2014 12:00:00 AM	7/14/2014 9:03 PM
Dates	Signed By Date	Insert			7/14/2014 12:00:00 AM	7/14/2014 9:03 PM
Dates	Start Date	Insert				7/14/2014 9:03 PM
Terminations	Termination Comments	Insert				7/14/2014 9:03 PM
Terminations	Termination Date	Insert				7/14/2014 9:03 PM
Terminations	Termination Effective Date	Insert				7/14/2014 9:03 PM
Terminations	Termination Reason	Insert				7/14/2014 9:03 PM