Covered Entity Details

CAH501332-09 TRI-STATE MEMORIAL HOSPITAL (Active) - information as of 6/9/2025 11:06:02 PM

Main Details

Name

TRI-STATE MEMORIAL HOSPITAL

Subdivision Name

TRI-STATE MEMORIAL HOSPITAL WOUND HEALING/PODIATRY

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH501332-09

Medicare Provider Number

501332

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/14/2015

Participating Start Date

4/1/2015

Participating Approval Date

2/10/2015

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Tri-State Memorial Hospital
Dave Storey, Director of Pharmacy
(509) 758-5511 Ext: 5080

Primary Contact

Tri-State Memorial Hospital
Jim Heilsberg, CFO
(509) 780-4667

Addresses

Street Address

1119 HIGHLAND AVE SUITE 7
TRI STATE MEDICAL CLINICS
CLARKSTON, WA 99403-2836

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?
No

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
CAH501332-01	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE MEMORIAL HOSPITAL / PRIMARY CARE CLINICS	1119 HIGHLAND AVENUE SUITE 10	CLARKSTON	WA	Active
CAH501332-02	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE MEMORIAL HOSPITAL, INC / Sleep Lab	1119 HIGHLAND AVE SUITE 8	CLARKSTON	WA	Active
CAH501332-03	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE MEMORIAL HOSPITAL / Ellison	1119 HIGHLAND AVENUE SUITE A	CLARKSTON	WA	Terminated
CAH501332-04	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE MEMORIAL HOSPITAL / Weiland	1119 HIGHLAND AVENUE SUITE A	CLARKSTON	WA	Terminated
CAH501332-05	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE UROLOGY CLINIC	1119 HIGHLAND AVE SUITE 1	CLARKSTON	WA	Active
CAH501332-06	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE MEMORIAL HOSPITAL / Surgery Clinic	1119 HIGHLAND AVE SUITE 6	CLARKSTON	WA	Terminated
CAH501332-07	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE HYPERTENSION & KIDNEY CLINIC	1119 HIGHLAND AVE SUITE 5	CLARKSTON	WA	Active
CAH501332-08	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE PULMONOLGY CLINIC	1119 HIGHLAND AVE, SUITE 2	Clarkston	WA	Active
CAH501332-09	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE MEMORIAL HOSPITAL WOUND HEALING/PODIATRY	1119 HIGHLAND AVE SUITE 7	CLARKSTON	WA	Active
CAH501332-10	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	Tri-State Rheumatology Clinic	1119 Highland Avenue SUITE 3	Clarkston	WA	Active
CAH501332-11	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	Tri-State Interventional Pain Consultants	1119 Highland Avenue Suite 11	Clarkston	WA	Active
CAH501332-12	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE MEMORIAL HOSPITAL - CLINIC MINOR CARE	1267 BELMONT WAY	CLARKSTON	WA	Active
CAH501332-13	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	TRI-STATE BEHAVIORAL HEALTH CLINIC	1271 HIGHLAND AVE	CLARKSTON	WA	Active
CAH501332-14	Child	CAH	TRI-STATE MEMORIAL HOSPITAL	Tri-State Surgical Clinic - General Surgery Clinic	1119 HIGHLAND AVE, SUITE 4	Clarkston	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 4:08:33 PM	8/16/2024 1:37:21 PM	8/16/2024 1:37 PM
Details	Last Recertification Date	Update	Recertification	8/24/2022 12:56:42 PM	8/16/2023 4:08:33 PM	8/16/2023 4:08 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 2:49:22 PM	8/24/2022 12:56:42 PM	8/24/2022 12:56 PM
Contacts	Primary Contact	Update	Recertification	Storey, Dave Director of Pharmacy Tri-State Memorial Hospital 5097585511-5080	Heilsberg, Jim CFO Tri-State Memorial Hospital 5097804667	8/17/2021 2:49 PM
Details	Last Recertification Date	Update	Recertification	8/17/2020 10:43:02 AM	8/17/2021 2:49:22 PM	8/17/2021 2:49 PM
Contacts	Authorizing Official	Update	AO Change Request	Leonard, Julie L CFO Tri-State Memorial Hospital 5097584667-4670	Storey, Dave Director of Pharmacy Tri-State Memorial Hospital 5097585511-5080	8/17/2020 11:56 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 4:40:41 PM	8/17/2020 10:43:02 AM	8/17/2020 10:43 AM
Details	Last Recertification Date	Update	Recertification	8/30/2018 1:38:06 PM	8/20/2019 4:40:41 PM	8/20/2019 4:40 PM
Contacts	Authorizing Official	Update	AO Change Request	ATTRIDGE, SCOT CFO TRI-STATE MEMORIAL HOSPITAL 5097584667	Leonard, Julie L CFO Tri-State Memorial Hospital 5097584667-4670	4/17/2019 9:59 AM
Addresses	Main Address	Update	Recertification	1119 HIGHLAND AVE SUITE 7 & 9 TRI STATE MEDICAL CLINICS CLARKSTON, WA 99403-2836	1119 HIGHLAND AVE SUITE 7 TRI STATE MEDICAL CLINICS CLARKSTON, WA 99403-2836	8/30/2018 1:38 PM
Details	Last Recertification Date	Update	Recertification	11/9/2017 1:23:27 PM	8/30/2018 1:38:06 PM	8/30/2018 1:38 PM
Details	Entity Subname	Update	Recertification	TRI-STATE MEMORIAL HOSPITAL / Clinic-Wound Care Clinic and Primary Care Clinic	TRI-STATE MEMORIAL HOSPITAL WOUND HEALING/PODIATRY	8/30/2018 1:38 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	11/9/2017 1:23:27 PM	11/9/2017 1:23 PM
Contacts	Authorizing Official	Update	AO Change Request	TOWN, ALEX CFO 5097584667	ATTRIDGE, SCOT CFO TRI-STATE MEMORIAL HOSPITAL 5097584667	11/8/2017 1:01 PM
Contacts	Signed By	Update		TOWN, ALEX CFO 5097584667	TOWN, ALEX CFO Tri-State Memorial Hospital 5097584667	9/25/2017 12:15 PM
Contacts	Primary Contact	Update		Storey, Dave Director of Pharmacy 5097585511-5080	Storey, Dave Director of Pharmacy Tri-State Memorial Hospital 5097585511-5080	9/22/2017 2:01 PM
Addresses	Main Address	Insert			1119 HIGHLAND AVE SUITE 7 & 9 TRI STATE MEDICAL CLINICS CLARKSTON, WA 99403-2836	1/17/2017 3:00 PM
Contacts	Authorizing Official	Insert			TOWN, ALEX CFO 5097584667	1/17/2017 3:00 PM
Contacts	Signed By	Insert			TOWN, ALEX CFO 5097584667	1/17/2017 3:00 PM
Contacts	Primary Contact	Insert			Storey, Dave Director of Pharmacy 5097585511-5080	1/17/2017 3:00 PM
Details	Last Recertification Date	Update		8/7/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/1/2016 12:37 PM
Details	Last Recertification Date	Update			8/7/2015 12:00:00 AM	8/7/2015 8:01 PM
Dates	Participating Approval Date	Update			2/10/2015 12:00:00 AM	2/10/2015 5:07 AM
Details	State	Update		Pending	Active	2/10/2015 5:07 AM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	2/10/2015 5:07 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_49280	CAH501332-09	1/15/2015 10:01 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_49280	1/14/2015 3:11 PM
Details	Last Recertification Date	Insert				1/14/2015 3:11 PM
Details	Grant Number	Insert				1/14/2015 3:11 PM
Details	340B ID	Insert				1/14/2015 3:11 PM
Details	Is Authorizing Official EHB Data	Insert				1/14/2015 3:11 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/14/2015 3:11 PM
Details	Medicare Provider Number	Insert			501332	1/14/2015 3:11 PM
Details	Entity Name	Insert			TRI-STATE MEMORIAL HOSPITAL	1/14/2015 3:11 PM
Details	Program Code	Insert			CAH	1/14/2015 3:11 PM
Details	Entity Subname	Insert			TRI-STATE MEMORIAL HOSPITAL / Clinic-Wound Care Clinic and Primary Care Clinic	1/14/2015 3:11 PM
Dates	Participating Approval Date	Insert				1/14/2015 3:11 PM
Details	State	Insert			Pending	1/14/2015 3:11 PM
Dates	Registration Date	Insert			1/14/2015 12:00:00 AM	1/14/2015 3:11 PM
Dates	Signed By Date	Insert			1/14/2015 12:00:00 AM	1/14/2015 3:11 PM
Dates	Start Date	Insert				1/14/2015 3:11 PM
Terminations	Termination Comments	Insert				1/14/2015 3:11 PM
Terminations	Termination Date	Insert				1/14/2015 3:11 PM
Terminations	Termination Effective Date	Insert				1/14/2015 3:11 PM
Terminations	Termination Reason	Insert				1/14/2015 3:11 PM