Covered Entity Details

DSH380038 PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER (Active) - information as of 5/9/2025 12:09:49 AM

Main Details

Name

PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH380038

Medicare Provider Number

380038

Additional Details

Current Program Status

Active

Registration Date

4/9/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/20/2015

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Providence Willamette Falls Medical Center
Brad Walker Henry, Chief Executive
(503) 657-6915

Primary Contact

Providence Health and Services
Mac Ovenell, 340B Director
(509) 860-8643

Addresses

Street Address

1500 DIVISION STREET
OREGON CITY, OR 97045

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
OR	217653	1912282369
WA	2033970	1912282369
AK		1912282369
CA		1912282369
ID		1912282369

Shipping Addresses

Shipping Address 1

PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
1500 DIVISION STREET
OREGON CITY, OR 97045

Shipping Address 2

PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER - INFUSION
1500 DIVISION STREET
STE 220
OREGON CITY, OR 97045

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/12/2018	04/01/2018		01/12/2018
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/12/2018	04/01/2018		01/12/2018
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/12/2018	04/01/2018		01/12/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/12/2018	04/01/2018		01/12/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/12/2018	04/01/2018		01/12/2018
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/12/2018	04/01/2018		01/12/2018
Contract Detail	AETNA SPECIALTY PHARMACY, LLC	503 SUNPORT LN		ORLANDO	FL	32809-7874	04/12/2019	07/01/2019		07/01/2019
Contract Detail	ARDON HEALTH, LLC	11835 NE GLENN WIDING DR		PORTLAND	OR	97220-9057	07/12/2019	10/01/2019		10/01/2019
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	7358 S W DURHAM ROAD	PORTLAND	OR	97224	01/12/2018	04/01/2018		01/12/2018
Contract Detail	CREDENA HEALTH LLC	7376 SW DURHAM RD		PORTLAND	OR	97224	10/17/2022	01/01/2023		01/01/2023
Contract Detail	CREDENA HEALTH PHARMACY PPMC PLAZA	5050 NE HOYT ST STE 142		PORTLAND	OR	97213	04/12/2019	07/01/2019	07/01/2019	04/14/2020
Contract Detail	CREDENA HEALTH PHARMACY PPMC PLAZA	5050 NE HOYT ST STE 142		PORTLAND	OR	97213	04/12/2019	07/01/2019		07/01/2019
Contract Detail	CREDENA HEALTH, LLC	6348 NE HALSEY ST	SUITE A	PORTLAND	OR	97213-4720	07/18/2017	10/01/2017		10/01/2017
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	01/12/2018	04/01/2018		01/12/2018
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	G3320 BEECHER RD		FLINT	MI	48532-3614	04/06/2018	07/01/2018		04/06/2018
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	04/06/2018	07/01/2018		04/06/2018
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF PHOENIX,	DIPLOMAT SPECIALTY PHARMACY	485 N. JUNIPER DR	CHANDLER	AZ	85226	07/16/2019	10/01/2019		10/01/2019
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN	DIPLOMAT SPECIALTY PHARMACY	1809 EXCISE AVENUE SUITE 204-208	ONTARIO	CA	91761	04/06/2018	07/01/2018	07/11/2019	07/16/2019
Contract Detail	FRED MEYER	CLACKAMAS STORE	16301 S E 82ND DRIVE	CLACKAMAS	OR	97015	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #651	1401 SE FIRST AVE	CANBY	OR	97013	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #240	14700 SE MCLOUGHLIN BLVD	MILWAUKIE	OR	97267-1417	07/15/2020	10/01/2020		10/01/2020
Contract Detail	FRED MEYER STORES INC	FRED MEYER PHARMACY #242	1839 MOLALLA AVENUE	OREGON CITY	OR	97045	07/15/2020	10/01/2020		10/01/2020
Contract Detail	HEALTHY OPTIONS INC	DBA POSTAL PRESCRIPTION SVCS	3500 SE 26TH AVE PO BOX 2718	PORTLAND	OR	97202	07/15/2020	10/01/2020		10/01/2020
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	01/07/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/18/2022	04/18/2022		04/21/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/07/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	01/07/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	01/07/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	01/07/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	01/07/2021	04/01/2021		04/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/07/2021	04/01/2021		04/01/2021
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	01/12/2018	04/01/2018		01/12/2018
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/12/2018	04/01/2018		01/12/2018
Contract Detail	PROVIDENCE HEALTH & SERVICES - OREGON	PROVIDENCE PLAZA PHARMACY	5050 NE HOYT STREET SUITE #142	PORTLAND	OR	97213	01/12/2018	04/01/2018	04/01/2019	04/14/2020
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #2690	4320 SE KING ROAD	MILWAUKIE	OR	97222	07/15/2020	10/01/2020		10/01/2020
Contract Detail	SAFEWAY INC	SAFEWAY PHARMACY #0382	3527 SE 122ND AVE	PORTLAND	OR	97236	07/15/2020	10/01/2020		10/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5352	10860 S.E. OAK STREET	MILWAUKIE	OR	97222	01/15/2020	04/01/2020		04/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5326	12002 SE SUNNYSIDE ROAD	CLACKAMAS	OR	97015	01/15/2020	04/01/2020		04/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5332	1900 MCLOUGHLIN BLVD.	OREGON CITY	OR	97045	01/15/2020	04/01/2020		04/01/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5331	16390 BOONES FERRY ROAD	LAKE OSWEGO	OR	97035	01/15/2020	04/01/2020		04/01/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-3144	15600 SE MCLOUGHLIN BLVD		MILWAUKIE	OR	97267	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5440	10000 SOUTHEAST 82ND AVENUE		HAPPY VALLEY	OR	97086	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5994	19133 WILLAMETTE DR.		WEST LINN	OR	97068	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16403	1409 11TH AVE.	SEATTLE	WA	98122	01/12/2018	04/01/2018		01/12/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03801	1310 MOLALLA AVE	OREGON CITY	OR	97045	01/12/2018	04/01/2018		01/12/2018
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	04/12/2019	07/01/2019		07/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/12/2018	04/01/2018	10/01/2021	01/14/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/12/2018	04/01/2018		01/12/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/12/2018	04/01/2018		01/12/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/12/2018	04/01/2018		01/12/2018
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	04/12/2019	07/01/2019		07/01/2019

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH380038A	Child	DSH	PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER	OUTPATIENT INFUSION CLINIC - OUTPATIENT INFUSIONS	1510 Division Street	OREGON CITY	OR	Active
DSH380038B	Child	DSH	PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER	RHEUMATOLOGY - RHEUMATOLOGY	1510 Division Street	Oregon City	OR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/1/2023 12:26:24 PM	8/13/2024 8:18:47 PM	8/13/2024 8:18 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 3:48:50 PM	9/1/2023 12:26:24 PM	9/1/2023 12:26 PM
Addresses	Shipping Address	Insert	Change Request		PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER 1500 DIVISION STREET OREGON CITY, OR 97045	3/15/2023 7:55 AM
Addresses	Shipping Address	Insert	Change Request		PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER - INFUSION 1500 DIVISION STREET STE 220 OREGON CITY, OR 97045	3/15/2023 7:55 AM
Details	Last Recertification Date	Update	Recertification	9/14/2021 3:06:22 PM	9/6/2022 3:48:50 PM	9/6/2022 3:48 PM
Contacts	Primary Contact	Update	Change Request	Conrad, Greg Sr. Mgr. PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER 5036506820	Ovenell, Mac 340B Director Providence Health and Services 5098608643	6/13/2022 11:49 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 4:12:30 PM	9/14/2021 3:06:22 PM	9/14/2021 3:06 PM
Contacts	Authorizing Official	Update	AO Change Request	Sawa, Kendall W Interim Chief Executive Officer PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER 5037236514	Henry, Brad Walker Chief Executive Providence Willamette Falls Medical Center 5036576915	6/17/2021 7:42 AM
Contacts	Authorizing Official	Update	Change Request	Reinhard, Russell P. Chief Executive Providence Willamette Falls Medical Center 5036576915	Sawa, Kendall W Interim Chief Executive Officer PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER 5037236514	4/21/2021 2:39 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912282369	9/2/2020 4:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/2/2020 4:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912282369	9/2/2020 4:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/2/2020 4:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912282369	9/2/2020 4:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/2/2020 4:12 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1912282369	9/2/2020 4:12 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/2/2020 4:12 PM
Medicaid Billing	NPI: State	Update	Recertification		OR	9/2/2020 4:12 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 5:47:39 AM	9/2/2020 4:12:30 PM	9/2/2020 4:12 PM
Contacts	Primary Contact	Update	Profile Change Request	Conrad, Greg Director of Pharmacy PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER 5036506820	Conrad, Greg Sr. Mgr. PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER 5036506820	4/13/2020 7:28 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 3:51:10 PM	8/22/2019 5:47:39 AM	8/22/2019 5:47 AM
Details	Last Recertification Date	Update	Recertification	12/1/2017 3:33:59 PM	8/22/2018 3:51:10 PM	8/22/2018 3:51 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	12/1/2017 3:33:59 PM	12/1/2017 3:33 PM
Contacts	Authorizing Official	Update		Reinhard, Russell P. Chief Executive 5036576915	Reinhard, Russell P. Chief Executive Providence Willamette Falls Medical Center 5036576915	10/9/2017 2:08 PM
Contacts	Signed By	Update		Reinhard, Russell P. Chief Executive 5036576915	Reinhard, Russell P. Chief Executive Providence Willamette Falls Medical Center 5036576915	10/9/2017 2:08 PM
Contacts	Primary Contact	Update		Conrad, Greg Director of Pharmacy 5036506820	Conrad, Greg Director of Pharmacy PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER 5036506820	9/27/2017 10:14 AM
Contacts	Authorizing Official	Insert			Reinhard, Russell P. Chief Executive 5036576915	7/18/2017 12:00 PM
Contacts	Signed By	Insert			Reinhard, Russell P. Chief Executive 5036576915	7/18/2017 12:00 PM
Addresses	Main Address	Insert			1500 DIVISION STREET OREGON CITY, OR 97045	8/10/2016 2:52 PM
Contacts	Primary Contact	Insert			Conrad, Greg Director of Pharmacy 5036506820	8/10/2016 2:52 PM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 2:52 PM
Details	Last Recertification Date	Update			8/14/2015 12:00:00 AM	8/14/2015 1:38 PM
Details	Entity Name	Update		WILLAMETTE FALLS MEDICAL CENTER	PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER	5/27/2015 8:52 AM
Dates	Participating Approval Date	Update			5/20/2015 12:00:00 AM	5/20/2015 1:59 PM
Details	State	Update		Pending	Active	5/20/2015 1:59 PM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/20/2015 1:59 PM
Details	340B ID	Update		ONLINE_REG_50971	DSH380038	4/9/2015 5:07 PM
Details	340B ID	Update			ONLINE_REG_50971	4/9/2015 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/9/2015 2:18 PM
Medicaid Billing	Medicaid: Number	Insert			217653	4/9/2015 2:18 PM
Medicaid Billing	Medicaid: State	Insert			OR	4/9/2015 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/9/2015 2:18 PM
Medicaid Billing	Medicaid: Number	Insert			2033970	4/9/2015 2:18 PM
Medicaid Billing	Medicaid: State	Insert			WA	4/9/2015 2:18 PM
Medicaid Billing	NPI: Number	Insert			1912282369	4/9/2015 2:18 PM
Details	Last Recertification Date	Insert				4/9/2015 2:18 PM
Details	Grant Number	Insert				4/9/2015 2:18 PM
Details	340B ID	Insert				4/9/2015 2:18 PM
Details	Is Authorizing Official EHB Data	Insert				4/9/2015 2:18 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/9/2015 2:18 PM
Details	Medicare Provider Number	Insert			380038	4/9/2015 2:18 PM
Details	Entity Name	Insert			WILLAMETTE FALLS MEDICAL CENTER	4/9/2015 2:18 PM
Details	Program Code	Insert			DSH	4/9/2015 2:18 PM
Details	Entity Subname	Insert				4/9/2015 2:18 PM
Dates	Participating Approval Date	Insert				4/9/2015 2:18 PM
Details	State	Insert			Pending	4/9/2015 2:18 PM
Dates	Registration Date	Insert			4/9/2015 12:00:00 AM	4/9/2015 2:18 PM
Dates	Signed By Date	Insert			4/9/2015 12:00:00 AM	4/9/2015 2:18 PM
Dates	Start Date	Insert				4/9/2015 2:18 PM
Terminations	Termination Comments	Insert				4/9/2015 2:18 PM
Terminations	Termination Date	Insert				4/9/2015 2:18 PM
Terminations	Termination Effective Date	Insert				4/9/2015 2:18 PM
Terminations	Termination Reason	Insert				4/9/2015 2:18 PM