Covered Entity Details

CAH291309-00 BOULDER CITY HOSPITAL (Active) - information as of 5/29/2025 2:00:24 AM

Main Details

Name

BOULDER CITY HOSPITAL

Subdivision Name

Type

Critical Access Hospital

Rural

340B ID

CAH291309-00

Medicare Provider Number

291309

Additional Details

Current Program Status

Active

Registration Date

7/20/2015

Participating Start Date

10/1/2015

Participating Approval Date

8/7/2015

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Boulder City Hospital
Douglas B. Lewis, CFO
(702) 293-4111 Ext: 6509

Primary Contact

Boulder City Hospital
Roger Kent Waddington, Pharmacy Manager
(702) 293-4111 Ext: 1517

Addresses

Street Address

901 ADAMS BLVD
BOULDER CITY, NV 89005-2247

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	Termination Date	Last Updated On
Contract Detail	LONGS DRUG STORES CALIFORNIA, L.L.C.	DBA: CVS/PHARMACY # 09548	2501 ANTHEM VILLAGE DR	HENDERSON	NV	89052	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	NEVADA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01507	2935 S. HOLLYWOOD BLVD	LAS VEGAS	NV	89122	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	NEVADA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08799	1360 E. FLAMINGO RD.	LAS VEGAS	NV	89119	07/12/2019	10/01/2019	01/01/2020	01/07/2021
Contract Detail	NEVADA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08800	6705 E. LAKE MEAD BLVD	LAS VEGAS	NV	89156	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	NEVADA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08803	2855 S NELLIS BLVD	LAS VEGAS	NV	89121	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	NEVADA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08813	1017 NEVADA HIGHWAY	BOULDER CITY	NV	89005	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	NEVADA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08824	4411 E. BONANZA RD	LAS VEGAS	NV	89110	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	NEVADA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 09770	2830 BICENTENNIAL PKWY.	HENDERSON	NV	89044	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	WARM SPRINGS ROAD CVS, L.L.C.	DBA: CVS/PHARMACY # 05286	21 W. HORIZON RIDGE PARKWAY	HENDERSON	NV	89012	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	WARM SPRINGS ROAD CVS, L.L.C.	DBA: CVS/PHARMACY # 05792	2425 E. DESERT INN RD.	LAS VEGAS	NV	89121	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	WARM SPRINGS ROAD CVS, L.L.C.	CVS PHARMACY # 16079	4001 S MARYLAND PKWY	LAS VEGAS	NV	89119	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	WARM SPRINGS ROAD CVS, L.L.C.	CVS PHARMACY # 16531	9725 S EASTERN AVE	LAS VEGAS	NV	89183	07/12/2019	10/01/2019	04/11/2022	04/11/2022
Contract Detail	WARM SPRINGS ROAD CVS, L.L.C.	DBA: CVS/PHARMACY # 02930	4595 E. FLAMINGO RD.	LAS VEGAS	NV	89121	10/10/2019	01/01/2020	04/11/2022	04/11/2022
Contract Detail	WASHINGTON LAMB CVS, L.L.C.	DBA: CVS/PHARMACY # 03172	4391 E. WASHINGTON AVE.	LAS VEGAS	NV	89110	07/12/2019	10/01/2019	04/11/2022	04/11/2022

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 3:13:49 PM	8/22/2024 7:51:41 AM	8/22/2024 7:51 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 10:30:51 AM	8/17/2023 3:13:49 PM	8/17/2023 3:13 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 11:08:05 AM	8/30/2022 10:30:51 AM	8/30/2022 10:30 AM
Details	Last Recertification Date	Update	Recertification	9/4/2020 11:24:32 AM	8/23/2021 11:08:05 AM	8/23/2021 11:08 AM
Contacts	Primary Contact	Update	Change Request	Pastian, Andre Rene CNO Boulder City Hospital 7022934111-6512	Waddington, Roger Kent Pharmacy Manager Boulder City Hospital 7022934111-1517	7/19/2021 7:32 AM
Contacts	Primary Contact	Update	Change Request	West, Stephanie Pharmacy Manager Boulder City Hospital 7022945708	Pastian, Andre Rene CNO Boulder City Hospital 7022934111-6512	1/25/2021 10:35 AM
Contacts	Authorizing Official	Update	Profile Change Request	Lewis, Douglas B. CFO Boulder City Hospital 7022945709	Lewis, Douglas B. CFO Boulder City Hospital 7022934111-6509	1/7/2021 12:49 PM
Contacts	Signed By	Update	Profile Change Request	Lewis, Douglas B. CFO Boulder City Hospital 7022945709	Lewis, Douglas B. CFO Boulder City Hospital 7022934111-6509	1/7/2021 12:49 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 10:19:39 AM	9/4/2020 11:24:32 AM	9/4/2020 11:24 AM
Details	Last Recertification Date	Update	Recertification	8/27/2018 9:13:16 AM	8/26/2019 10:19:39 AM	8/26/2019 10:19 AM
Contacts	Primary Contact	Update	Change Request	Belete, Frey Controller Boulder City Hospital 7022945711	West, Stephanie Pharmacy Manager Boulder City Hospital 7022945708	8/29/2018 4:48 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 1:10:20 PM	8/27/2018 9:13:16 AM	8/27/2018 9:13 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1102839 (NV)		11/15/2017 1:10 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1881739613 ( )		11/15/2017 1:10 PM
Contacts	Primary Contact	Update	Recertification	Lewis, Douglas B. CFO 7022945709	Belete, Frey Controller Boulder City Hospital 7022945711	11/15/2017 1:10 PM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/15/2017 1:10:20 PM	11/15/2017 1:10 PM
Contacts	Authorizing Official	Update		Lewis, Douglas B. CFO 7022945709	Lewis, Douglas B. CFO Boulder City Hospital 7022945709	10/30/2017 5:16 PM
Contacts	Signed By	Update		Lewis, Douglas B. CFO 7022945709	Lewis, Douglas B. CFO Boulder City Hospital 7022945709	10/30/2017 5:16 PM
Addresses	Main Address	Insert			901 ADAMS BLVD BOULDER CITY, NV 89005-2247	8/15/2016 6:47 PM
Contacts	Authorizing Official	Insert			Lewis, Douglas B. CFO 7022945709	8/15/2016 6:47 PM
Contacts	Primary Contact	Insert			Lewis, Douglas B. CFO 7022945709	8/15/2016 6:47 PM
Contacts	Signed By	Insert			Lewis, Douglas B. CFO 7022945709	8/15/2016 6:47 PM
Details	Last Recertification Date	Update			8/15/2016 12:00:00 AM	8/15/2016 6:47 PM
Dates	Participating Approval Date	Update			8/7/2015 12:00:00 AM	8/7/2015 10:50 AM
Details	State	Update		Pending	Active	8/7/2015 10:50 AM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	8/7/2015 10:50 AM
Details	340B ID	Update		ONLINE_REG_54072	CAH291309-00	8/7/2015 10:15 AM
Details	340B ID	Update			ONLINE_REG_54072	7/20/2015 5:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/20/2015 5:19 PM
Medicaid Billing	Medicaid: Number	Insert			1102839	7/20/2015 5:19 PM
Medicaid Billing	Medicaid: State	Insert			NV	7/20/2015 5:19 PM
Medicaid Billing	NPI: Number	Insert			1881739613	7/20/2015 5:19 PM
Details	Last Recertification Date	Insert				7/20/2015 5:19 PM
Details	Grant Number	Insert				7/20/2015 5:19 PM
Details	340B ID	Insert				7/20/2015 5:19 PM
Details	Is Authorizing Official EHB Data	Insert				7/20/2015 5:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/20/2015 5:19 PM
Details	Medicare Provider Number	Insert			291309	7/20/2015 5:19 PM
Details	Entity Name	Insert			BOULDER CITY HOSPITAL	7/20/2015 5:19 PM
Details	Program Code	Insert			CAH	7/20/2015 5:19 PM
Details	Entity Subname	Insert				7/20/2015 5:19 PM
Dates	Participating Approval Date	Insert				7/20/2015 5:19 PM
Details	State	Insert			Pending	7/20/2015 5:19 PM
Dates	Registration Date	Insert			7/20/2015 12:00:00 AM	7/20/2015 5:19 PM
Dates	Signed By Date	Insert			7/20/2015 12:00:00 AM	7/20/2015 5:19 PM
Dates	Start Date	Insert				7/20/2015 5:19 PM
Terminations	Termination Comments	Insert				7/20/2015 5:19 PM
Terminations	Termination Date	Insert				7/20/2015 5:19 PM
Terminations	Termination Effective Date	Insert				7/20/2015 5:19 PM
Terminations	Termination Reason	Insert				7/20/2015 5:19 PM