Covered Entity Details

CAH051321-03 NorCal HealthConnect LLC- DBA Healdsburg Hospital (Active) - information as of 5/20/2025 12:53:14 AM

Main Details

Name

NorCal HealthConnect LLC- DBA Healdsburg Hospital

Subdivision Name

Outpatient Services-Medical Services at Medical Services

Type

Critical Access Hospital

Rural

340B ID

CAH051321-03

Medicare Provider Number

051321

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2015

Participating Start Date

7/1/2015

Participating Approval Date

6/10/2015

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Providence St Joseph Health
Erika Wright, CFO
(707) 525-5300

Primary Contact

Providence
Jesse Peterson, 340B Program Director, South Division
(651) 324-2207

Addresses

Street Address

1312 Prentice Dr
Healdsburg, CA 95448-3382

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
CA		1861009672

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
CAH051321-01	Child	CAH	NorCal HealthConnect LLC- DBA Healdsburg Hospital	Occupational Medicine	1312 Prentice Dr	Healdsburg	CA	Active
CAH051321-02	Child	CAH	NorCal HealthConnect LLC- DBA Healdsburg Hospital	Wound Care	1540 Healdsburg Ave	Healdsburg	CA	Active
CAH051321-03	Child	CAH	NorCal HealthConnect LLC- DBA Healdsburg Hospital	Outpatient Services-Medical Services at Medical Services	1312 Prentice Dr	Healdsburg	CA	Active
CAH051321-04	Child	CAH	NorCal HealthConnect LLC- DBA Healdsburg Hospital	Healdsburg Hospital Behavioral Health Services	1312 Prentice Drive	Healdsburg	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
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	11/1/2024 1:16 PM
Contacts	Authorizing Official	Update	Change Request	Naotunne, Bharatha CFO NorCal Health Connect 7074316523	Wright, Erika CFO Providence St Joseph Health 7075255300	10/24/2024 8:38 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1194824573 (CA)		8/12/2024 8:14 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1861009672	8/12/2024 8:14 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/12/2024 8:14 PM
Details	Last Recertification Date	Update	Recertification	9/7/2023 2:05:59 PM	8/12/2024 8:14:33 PM	8/12/2024 8:14 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 11:45:14 AM	9/7/2023 2:05:59 PM	9/7/2023 2:05 PM
Contacts	Authorizing Official	Update	Change Request	Pilgrim, Patti Regional CFO Providence St. Joseph Health 7075255323	Naotunne, Bharatha CFO NorCal Health Connect 7074316523	4/26/2023 2:35 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1194824573	9/6/2022 11:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/6/2022 11:45 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 2:56:08 PM	9/6/2022 11:45:14 AM	9/6/2022 11:45 AM
Details	Entity Name	Update	Change Request	HEALDSBURG DISTRICT HOSPITAL	NorCal HealthConnect LLC- DBA Healdsburg Hospital	7/19/2022 12:48 PM
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	8/26/2020 4:56:32 PM	8/27/2021 2:56:08 PM	8/27/2021 2:56 PM
Contacts	Authorizing Official	Update	Change Request	Kaemmerling, Berta Beadel Chief Nursing Officer Healdsburg 7074316327	Pilgrim, Patti Regional CFO Providence St. Joseph Health 7075255323	4/8/2021 1:35 PM
Contacts	Primary Contact	Update	Change Request	LE, MYTRANG DOP HEALDSBURG DISTRICT HOSPITAL 7074316432	Hanson, Victoria Marie 340B Program Manager Northern CA Region Providence St Joseph Health 7076722135	4/8/2021 10:26 AM
Contacts	Authorizing Official	Update	New Registration	Kaemmerling, Berta Beadel Chief Nursing Officer Healdsburg 7074316327	Kaemmerling, Berta Beadel Chief Nursing Officer Healdsburg 7074316327	8/31/2020 6:40 PM
Details	Last Recertification Date	Update	Recertification	9/9/2019 3:30:04 PM	8/26/2020 4:56:32 PM	8/26/2020 4:56 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 5:07:25 PM	9/9/2019 3:30:04 PM	9/9/2019 3:30 PM
Details	Entity Subname	Update	Change Request	Outpatient Services-Medical Services at Medical Services Ste D	Outpatient Services-Medical Services at Medical Services	11/15/2018 6:09 AM
Addresses	Main Address	Update	Change Request	1310 Prentice Dr Suite D Healdsburg, CA 95448-3382	1312 Prentice Dr Healdsburg, CA 95448-3382	10/18/2018 6:33 AM
Details	Last Recertification Date	Update	Recertification	11/6/2017 10:25:20 PM	8/16/2018 5:07:25 PM	8/16/2018 5:07 PM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	11/6/2017 10:25:20 PM	11/6/2017 10:25 PM
Contacts	Primary Contact	Update	Change Request	Goodfellow-Schmid, Nancy Chief Executive Officer Healdsburg District Hospital 7074316500-6523	LE, MYTRANG DOP HEALDSBURG DISTRICT HOSPITAL 7074316432	10/23/2017 9:34 PM
Contacts	Authorizing Official	Update	AO Change Request	Goodfellow-Schmid, Nancy Chief Executive Officer Healdsburg District Hospital 7074316500-6523	Kaemmerling, Berta Beadel Chief Nursing Officer Healdsburg 7074316327	10/4/2017 9:26 AM
Addresses	Main Address	Insert			1310 Prentice Dr Suite D Healdsburg, CA 95448-3382	9/6/2016 5:01 PM
Contacts	Authorizing Official	Insert			Goodfellow-Schmid, Nancy Chief Executive Officer Healdsburg District Hospital 7074316500-6523	9/6/2016 5:01 PM
Contacts	Primary Contact	Insert			Goodfellow-Schmid, Nancy Chief Executive Officer Healdsburg District Hospital 7074316500-6523	9/6/2016 5:01 PM
Contacts	Signed By	Insert			Goodfellow-Schmid, Nancy Chief Executive Officer Healdsburg District Hospital 7074316500-6523	9/6/2016 5:01 PM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 5:01 PM
Details	Last Recertification Date	Update			8/25/2015 12:00:00 AM	8/25/2015 4:11 PM
Dates	Participating Approval Date	Update			6/10/2015 12:00:00 AM	6/10/2015 10:27 AM
Details	State	Update		Pending	Active	6/10/2015 10:27 AM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	6/10/2015 10:27 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_51622	CAH051321-03	5/13/2015 10:28 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_51622	4/15/2015 1:58 PM
Details	Last Recertification Date	Insert				4/15/2015 1:58 PM
Details	Grant Number	Insert				4/15/2015 1:58 PM
Details	340B ID	Insert				4/15/2015 1:58 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2015 1:58 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2015 1:58 PM
Details	Medicare Provider Number	Insert			051321	4/15/2015 1:58 PM
Details	Entity Name	Insert			HEALDSBURG DISTRICT HOSPITAL	4/15/2015 1:58 PM
Details	Program Code	Insert			CAH	4/15/2015 1:58 PM
Details	Entity Subname	Insert			Outpatient Services-Medical Services at Medical Services Ste D	4/15/2015 1:58 PM
Dates	Participating Approval Date	Insert				4/15/2015 1:58 PM
Details	State	Insert			Pending	4/15/2015 1:58 PM
Dates	Registration Date	Insert			4/15/2015 12:00:00 AM	4/15/2015 1:58 PM
Dates	Signed By Date	Insert			4/15/2015 12:00:00 AM	4/15/2015 1:58 PM
Dates	Start Date	Insert				4/15/2015 1:58 PM
Terminations	Termination Comments	Insert				4/15/2015 1:58 PM
Terminations	Termination Date	Insert				4/15/2015 1:58 PM
Terminations	Termination Effective Date	Insert				4/15/2015 1:58 PM
Terminations	Termination Reason	Insert				4/15/2015 1:58 PM