| Contacts | Primary Contact | Update | Group Change Request | Hanson, Victoria Marie
Regional Pharmacy 340B Manager
Providence St Joseph Health
7076722135 | Peterson, Jesse
340B Program Director, South Division
Providence
6513242207 | 11/7/2024 7:53 AM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2023 5:40:47 PM | 8/13/2024 12:39:57 PM | 8/13/2024 12:39 PM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2022 11:53:09 AM | 9/7/2023 5:40:47 PM | 9/7/2023 5:40 PM |
| Contacts | Authorizing Official | Update | Change Request | Pilgrim, Patti
Regional CFO
Providence St. Joseph Health
7075255323 | Wright, Erika
CFO
Providence St Joseph Health
7075255300 | 5/1/2023 7:13 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 2:58:49 PM | 9/6/2022 11:53:09 AM | 9/6/2022 11:53 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Hanson, Victoria Marie
340B Program Manager Northern CA Region
Providence St Joseph Health
7076722135 | Hanson, Victoria Marie
Regional Pharmacy 340B Manager
Providence St Joseph Health
7076722135 | 1/15/2022 2:52 PM |
| Details | Last Recertification Date | Update | Recertification | 9/14/2020 8:07:45 AM | 8/27/2021 2:58:49 PM | 8/27/2021 2:58 PM |
| Contacts | Primary Contact | Update | Change Request | Chellamy, Caroline
Regional Director, 340B Operations
Providence St. Joseph Health
4242593784 | Hanson, Victoria Marie
340B Program Manager Northern CA Region
Providence St Joseph Health
7076722135 | 10/14/2020 7:12 AM |
| Contacts | Authorizing Official | Update | Change Request | Klockenga, Kevin
CEO
St. Joseph Health
7075221520 | Pilgrim, Patti
Regional CFO
Providence St. Joseph Health
7075255323 | 9/18/2020 6:35 AM |
| Addresses | Shipping Address | Delete | Recertification | Santa Rosa Memorial Hospital
1165 Montgomery Drive
Santa Rosa, CA 95405 | | 9/14/2020 8:07 AM |
| Addresses | Shipping Address | Insert | Recertification | | St Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
1165 Montgomery Drive
Santa Rosa, CA 95405 | 9/14/2020 8:07 AM |
| Addresses | Billing Address | Update | Recertification | Santa Rosa Memorial Hospital
1165 Montgomery Drive
Santa Rosa, CA 95405 | St Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
1165 Montgomery Drive
Santa Rosa, CA 95405 | 9/14/2020 8:07 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | CA | 9/14/2020 8:07 AM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2019 6:43:01 PM | 9/14/2020 8:07:45 AM | 9/14/2020 8:07 AM |
| 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 | 7/27/2020 1:32 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 | 5/5/2020 8:05 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2018 1:10:47 PM | 8/20/2019 6:43:01 PM | 8/20/2019 6:43 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 | 10/25/2018 3:17 PM |
| Details | Last Recertification Date | Update | Recertification | 11/9/2017 2:16:53 PM | 8/16/2018 1:10:47 PM | 8/16/2018 1:10 PM |
| Details | Entity Name | Update | Change Request | SANTA ROSA MEMORIAL HOSPITAL | ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital | 6/27/2018 1:42 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 6:15 PM |
| Contacts | Authorizing Official | Update | Change Request | Petrina, Robert
CFO
St. Josepsh Health
7075255320 | Iyer, Raju
Regional CFO
St. Joseph Health
7078068781 | 4/13/2018 7:47 AM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2016 12:00:00 AM | 11/9/2017 2:16:53 PM | 11/9/2017 2:16 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 | | |
500 Doyle Park Drive
Suite 202
Santa Rosa, CA 95405 | 6/13/2017 8:06 AM |
| Addresses | Billing Address | Insert | | | Santa Rosa Memorial Hospital
1165 Montgomery Drive
Santa Rosa, CA 95405 | 6/13/2017 8:06 AM |
| Addresses | Shipping Address | Insert | | | Santa Rosa Memorial Hospital
1165 Montgomery Drive
Santa Rosa, CA 95405 | 6/13/2017 8:06 AM |
| Details | Last Recertification Date | Update | | 8/6/2015 12:00:00 AM | 8/22/2016 12:00:00 AM | 8/22/2016 7:45 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 5:38 PM |
| Dates | Participating Approval Date | Update | | | 3/6/2015 12:00:00 AM | 3/6/2015 1:35 PM |
| Details | State | Update | | Pending | Active | 3/6/2015 1:35 PM |
| Dates | Start Date | Update | | | 4/1/2015 12:00:00 AM | 3/6/2015 1:35 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_48786 | DSH050174J | 1/23/2015 3:26 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_48786 | 1/12/2015 7:41 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1134152549 | 1/12/2015 7:41 PM |
| Details | Last Recertification Date | Insert | | | | 1/12/2015 7:41 PM |
| Details | Grant Number | Insert | | | | 1/12/2015 7:41 PM |
| Details | 340B ID | Insert | | | | 1/12/2015 7:41 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/12/2015 7:41 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/12/2015 7:41 PM |
| Details | Medicare Provider Number | Insert | | | 050174 | 1/12/2015 7:41 PM |
| Details | Entity Name | Insert | | | SANTA ROSA MEMORIAL HOSPITAL | 1/12/2015 7:41 PM |
| Details | Program Code | Insert | | | DSH | 1/12/2015 7:41 PM |
| Details | Entity Subname | Insert | | | SRMH - Wound Care Clinic / Wound Care Clinic | 1/12/2015 7:41 PM |
| Dates | Participating Approval Date | Insert | | | | 1/12/2015 7:41 PM |
| Details | State | Insert | | | Pending | 1/12/2015 7:41 PM |
| Dates | Registration Date | Insert | | | 1/12/2015 12:00:00 AM | 1/12/2015 7:41 PM |
| Dates | Signed By Date | Insert | | | 1/12/2015 12:00:00 AM | 1/12/2015 7:41 PM |
| Dates | Start Date | Insert | | | | 1/12/2015 7:41 PM |
| Terminations | Termination Comments | Insert | | | | 1/12/2015 7:41 PM |
| Terminations | Termination Date | Insert | | | | 1/12/2015 7:41 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/12/2015 7:41 PM |
| Terminations | Termination Reason | Insert | | | | 1/12/2015 7:41 PM |