Covered Entity Details

CAH051310-01 Willits Hospital Inc., DBA Adventist Health Howard Memorial (Active) - information as of 6/2/2025 8:28:39 AM

Main Details

Name

Willits Hospital Inc., DBA Adventist Health Howard Memorial

Subdivision Name

Adventist Health Howard Memorial

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH051310-01

Medicare Provider Number

051310

Outpatient Facility Provider Number

058680

Additional Details

Current Program Status

Active

Registration Date

7/13/2015

Participating Start Date

10/1/2015

Participating Approval Date

7/28/2015

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

Adventist Health North Coast Network
Jeff Mock, Finance Officer, North Coast Network
(916) 406-1417

Primary Contact

Adventist Health Ukiah Valley
Tracy Dolmage, Pharmacy Analyst
(707) 463-7633

Addresses

Street Address

3 Marcela Drive, Suite C
Willits, CA 95490-5769

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		1437551652,1356339543

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
Contract Detail	ADVENTIST HEALTH HOWARD MEMORIAL	3 MARCELA DR STE B		WILLITS	CA	95490-5769	07/15/2020	10/01/2020		10/01/2020	10/01/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH051310-01	Child	CAH	Willits Hospital Inc., DBA Adventist Health Howard Memorial	Adventist Health Howard Memorial	3 Marcela Drive, Suite C	Willits	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 2:54:42 PM	8/18/2024 7:14:41 PM	8/18/2024 7:14 PM
Contacts	Authorizing Official	Update	Change Request	Shepardson, Dean Finance Officer Adventist Health North Coast Network 7074635357	Mock, Jeff Finance Officer, North Coast Network Adventist Health North Coast Network 9164061417	9/27/2023 8:57 AM
Contacts	Primary Contact	Update	Recertification	D'Anis, Matthew DIRECTOR OF PHARMACY Adventist Health Howard Memorial 7074563147	Dolmage, Tracy Pharmacy Analyst Adventist Health Ukiah Valley 7074637633	9/6/2023 2:54 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 1:51:51 PM	9/6/2023 2:54:42 PM	9/6/2023 2:54 PM
Contacts	Authorizing Official	Update	Change Request	Tetz, Warren Lee Finance Officer Adventist Health Ukiah Valley 7074563001	Shepardson, Dean Finance Officer Adventist Health North Coast Network 7074635357	6/22/2023 7:29 AM
Details	Last Recertification Date	Update	Recertification	8/19/2021 5:04:33 PM	9/8/2022 1:51:51 PM	9/8/2022 1:51 PM
Contacts	Authorizing Official	Update	Change Request	Parker, Bessant Medical Officer Adventist Health Howard Memorial 7074637693	Tetz, Warren Lee Finance Officer Adventist Health Ukiah Valley 7074563001	3/25/2022 12:22 PM
Details	Last Recertification Date	Update	Recertification	9/3/2020 8:18:41 PM	8/19/2021 5:04:33 PM	8/19/2021 5:04 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/3/2020 8:18 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/3/2020 8:18 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 11:52:52 AM	9/3/2020 8:18:41 PM	9/3/2020 8:18 PM
Contacts	Authorizing Official	Update	Change Request	Howe, Judson CFO Adventist Health Howard Memorial 7074563001	Parker, Bessant Medical Officer Adventist Health Howard Memorial 7074637693	8/13/2020 2:09 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 4:08:17 PM	8/26/2019 11:52:52 AM	8/26/2019 11:52 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1356339543	1/25/2019 2:40 PM
Details	Entity Name	Update	Change Request	Willits Hospital Inc.	Willits Hospital Inc., DBA Adventist Health Howard Memorial	10/25/2018 9:58 AM
Contacts	Primary Contact	Update	Recertification	Winter, Carrie Lynn Manager Pharmacy-Outpatient Adventist Health Howard Memorial 7074563005	D'Anis, Matthew DIRECTOR OF PHARMACY Adventist Health Howard Memorial 7074563147	8/28/2018 4:08 PM
Details	Last Recertification Date	Update	Recertification	11/10/2017 1:39:05 PM	8/28/2018 4:08:17 PM	8/28/2018 4:08 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/10/2017 1:39:05 PM	11/10/2017 1:39 PM
Contacts	Primary Contact	Update	Change Request	Lopez, George Interim Director of Pharmacy 7074563147	Winter, Carrie Lynn Manager Pharmacy-Outpatient Adventist Health Howard Memorial 7074563005	10/24/2017 10:41 AM
Details	Entity Subname	Update	Change Request	Redwood Medical Clinic	Adventist Health Howard Memorial	10/24/2017 10:41 AM
Details	Entity Name	Update	Change Request	HOWARD MEMORIAL HOSPITAL	Willits Hospital Inc.	10/23/2017 9:21 AM
Contacts	Authorizing Official	Update		Howe, Judson CFO 7074563001	Howe, Judson CFO Adventist Health Howard Memorial 7074563001	10/20/2017 4:08 PM
Contacts	Authorizing Official	Update		Scott, Karen VP of Patient Care 7074563010	Howe, Judson CFO 7074563001	6/5/2017 1:28 PM
Addresses	Main Address	Insert			3 Marcela Drive, Suite C Willits, CA 95490-5769	5/9/2017 12:01 PM
Medicaid Billing	NPI: Number	Update		1902273212	1437551652	5/9/2017 12:01 PM
Contacts	Primary Contact	Update		Lopez, George Interim Director of Pharmacy 7074563147	Lopez, George Interim Director of Pharmacy 7074563147	5/9/2017 12:01 PM
Contacts	Signed By	Insert			Sauder, Chris VP of Finance/CFO 7074563001	5/9/2017 12:01 PM
Contacts	Authorizing Official	Insert			Scott, Karen VP of Patient Care 7074563010	10/28/2016 4:24 PM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 4:09 PM
Medicaid Billing	NPI: Number	Update		1437551652	1902273212	6/10/2016 11:43 AM
Contacts	Primary Contact	Update		Forni, Peter DIRECTOR OF PHARMACY 7074563147	Lopez, George Interim Director of Pharmacy 7074563147	6/10/2016 8:00 AM
Contacts	Primary Contact	Insert			Forni, Peter DIRECTOR OF PHARMACY 7074563147	12/4/2015 7:35 AM
Dates	Participating Approval Date	Update			7/28/2015 12:00:00 AM	7/28/2015 2:56 PM
Details	State	Update		Pending	Active	7/28/2015 2:56 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	7/28/2015 2:56 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_53450	CAH051310-01	7/28/2015 2:23 PM
Details	Entity Name	Update		HOWARD MEMORIAL HOSPITA	HOWARD MEMORIAL HOSPITAL	7/28/2015 2:23 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_53450	7/13/2015 4:53 PM
Medicaid Billing	NPI: Number	Insert			1437551652	7/13/2015 4:53 PM
Details	Last Recertification Date	Insert				7/13/2015 4:53 PM
Details	Grant Number	Insert				7/13/2015 4:53 PM
Details	340B ID	Insert				7/13/2015 4:53 PM
Details	Is Authorizing Official EHB Data	Insert				7/13/2015 4:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/13/2015 4:53 PM
Details	Medicare Provider Number	Insert			051310	7/13/2015 4:53 PM
Details	Entity Name	Insert			HOWARD MEMORIAL HOSPITA	7/13/2015 4:53 PM
Details	Program Code	Insert			CAH	7/13/2015 4:53 PM
Details	Entity Subname	Insert			Redwood Medical Clinic	7/13/2015 4:53 PM
Dates	Participating Approval Date	Insert				7/13/2015 4:53 PM
Details	State	Insert			Pending	7/13/2015 4:53 PM
Dates	Registration Date	Insert			7/13/2015 12:00:00 AM	7/13/2015 4:53 PM
Dates	Signed By Date	Insert			7/13/2015 12:00:00 AM	7/13/2015 4:53 PM
Dates	Start Date	Insert				7/13/2015 4:53 PM
Terminations	Termination Comments	Insert				7/13/2015 4:53 PM
Terminations	Termination Date	Insert				7/13/2015 4:53 PM
Terminations	Termination Effective Date	Insert				7/13/2015 4:53 PM
Terminations	Termination Reason	Insert				7/13/2015 4:53 PM