Covered Entity Details

DSH050136A PETALUMA VALLEY HOSPITAL (Terminated) - information as of 5/27/2025 11:39:12 PM

Main Details

Name

PETALUMA VALLEY HOSPITAL

Subdivision Name

PVH - Lynch Creek Radiology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050136A

Medicare Provider Number

050136

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/12/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/11/2015

Last Recertification Date

8/20/2019

Termination Date
Termination Reason

10/1/2020
Hospital Outpatient facility no longer eligible

Contacts

Authorizing Official

Providence St. Joseph Health
Patti Pilgrim, Regional CFO
(707) 525-5323

Primary Contact

Providence St. Joseph Health
Caroline Chellamy, Regional Director, 340B Operations
(424) 259-3784

Addresses

Street Address

110 Lynch Creek Way
Suite B
Petaluma, CA 94954

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
		1235162645

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
DSH050136A	Child	DSH	PETALUMA VALLEY HOSPITAL	PVH - Lynch Creek Radiology	110 Lynch Creek Way	Petaluma	CA	Terminated
DSH050136B	Child	DSH	PETALUMA VALLEY HOSPITAL	PVH - Hospice of Petaluma	416 Payran Street	Petaluma	CA	Terminated
DSH050136C	Child	DSH	PETALUMA VALLEY HOSPITAL	MEMORIAL HOSPICE	439 COLLEGE AVE	SANTA ROSA	CA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Contacts	Authorizing Official	Update	Change Request	Klockenga, Kevin CEO St. Joseph Health 7075221520	Pilgrim, Patti Regional CFO Providence St. Joseph Health 7075255323	9/17/2020 3:43 PM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		6/29/2019 12:00:00 AM	9/14/2020 12:27 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/14/2020 12:27 PM
Terminations	Termination Comments	Update	Recertification		This radiology child site shows no revenue. It does not use drugs and no 340B purchased drugs were used since the end of fiscal year.	9/14/2020 12:27 PM
Terminations	Termination Date	Update	Recertification		10/1/2020 12:00:00 AM	9/14/2020 12:27 PM
Terminations	Termination Effective Date	Update	Recertification		6/30/2019 12:00:00 AM	9/14/2020 12:27 PM
Terminations	Termination Reason	Update	Recertification		Hospital Outpatient facility no longer eligible	9/14/2020 12:27 PM
Contacts	Primary Contact	Update	Change Request	Hanson, Victoria Marie 340B Program Manager Northern CA Region Providence St Joseph Health 7076722135	Chellamy, Caroline Regional Director, 340B Operations Providence St. Joseph Health 4242593784	7/7/2020 3:10 PM
Contacts	Primary Contact	Update	Change Request	Schuchard, Virginia Elizabeth NorCal Region 340B Program Manager St.Joseph Health 5072718661	Hanson, Victoria Marie 340B Program Manager Northern CA Region Providence St Joseph Health 7076722135	5/6/2020 1:11 PM
Details	Last Recertification Date	Update	Recertification	8/17/2018 6:00:55 PM	8/20/2019 6:46:38 PM	8/20/2019 6:46 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 7:19 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 2:29:26 PM	8/17/2018 6:00:55 PM	8/17/2018 6:00 PM
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 6:56 PM
Contacts	Authorizing Official	Update	Change Request	Petrina, Robert CFO St. Josepsh Health 7075255320	Iyer, Raju Regional CFO St. Joseph Health 7078068781	4/17/2018 12:45 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	11/9/2017 2:29:26 PM	11/9/2017 2:29 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			110 Lynch Creek Way Suite B Petaluma, CA 94954	6/13/2017 8:04 AM
Details	Last Recertification Date	Update		8/6/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 3:18 PM
Contacts	Primary Contact	Insert			Clougherty, Kevin Regional Director 340B Pharmacy Operations 7072694236	8/19/2016 10:33 AM
Details	Last Recertification Date	Update			8/6/2015 12:00:00 AM	8/6/2015 5:09 PM
Dates	Participating Approval Date	Update			3/11/2015 12:00:00 AM	3/11/2015 2:43 PM
Details	State	Update		Pending	Active	3/11/2015 2:43 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/11/2015 2:43 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_48776	DSH050136A	1/13/2015 7:14 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_48776	1/12/2015 5:56 PM
Medicaid Billing	NPI: Number	Insert			1235162645	1/12/2015 5:56 PM
Details	Last Recertification Date	Insert				1/12/2015 5:56 PM
Details	Grant Number	Insert				1/12/2015 5:56 PM
Details	340B ID	Insert				1/12/2015 5:56 PM
Details	Is Authorizing Official EHB Data	Insert				1/12/2015 5:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/12/2015 5:56 PM
Details	Medicare Provider Number	Insert			050136	1/12/2015 5:56 PM
Details	Entity Name	Insert			PETALUMA VALLEY HOSPITAL	1/12/2015 5:56 PM
Details	Program Code	Insert			DSH	1/12/2015 5:56 PM
Details	Entity Subname	Insert			PVH - Lynch Creek Radiology	1/12/2015 5:56 PM
Dates	Participating Approval Date	Insert				1/12/2015 5:56 PM
Details	State	Insert			Pending	1/12/2015 5:56 PM
Dates	Registration Date	Insert			1/12/2015 12:00:00 AM	1/12/2015 5:56 PM
Dates	Signed By Date	Insert			1/12/2015 12:00:00 AM	1/12/2015 5:56 PM
Dates	Start Date	Insert				1/12/2015 5:56 PM
Terminations	Termination Comments	Insert				1/12/2015 5:56 PM
Terminations	Termination Date	Insert				1/12/2015 5:56 PM
Terminations	Termination Effective Date	Insert				1/12/2015 5:56 PM
Terminations	Termination Reason	Insert				1/12/2015 5:56 PM