Covered Entity Details

CAH501323-05 JEFFERSON HEALTHCARE (Active) - information as of 5/20/2025 12:51:51 AM

Main Details

Name

JEFFERSON HEALTHCARE

Subdivision Name

Jefferson Healthcare Sheridan Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH501323-05

Medicare Provider Number

501323

Outpatient Facility Provider Number

508526

Additional Details

Current Program Status

Active

Registration Date

1/13/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/2/2016

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Jefferson Healthcare
Jacob Bujacich Davidson, Chief Operating Officer
(360) 385-2200 Ext: 2039

Primary Contact

Jefferson Healthcare
Andrew John Nelson, Director of Pharmacy
(360) 385-2200 Ext: 2345

Addresses

Street Address

915 SHERIDAN ST
PORT TOWNSEND, WA 98368-2957

Billing Address

Jefferson Healthcare Pharmacy
834 Sheridan St
Port Townsend, WA 98368

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

Shipping Address 1

Jefferson Healthcare Pharmacy
834 Sheridan St
Port Townsend, WA 98368

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
CAH501323-01	Child	CAH	JEFFERSON HEALTHCARE	South County Medical Clinic	294843 US HWY 101	QUILCENE	WA	Active
CAH501323-02	Child	CAH	JEFFERSON HEALTHCARE	Jefferson Healthcare Watership Clinic	1010 SHERIDAN STREET	PORT TOWNSEND	WA	Active
CAH501323-03	Child	CAH	JEFFERSON HEALTHCARE	JEFFERSON HEALTHCARE SURGICAL ASSOCIATES	1010 Sheridan	Port Townsend	WA	Active
CAH501323-04	Child	CAH	JEFFERSON HEALTHCARE	Jefferson Healthcare Townsend Clinic	934 Sheridan	Port Townsend	WA	Active
CAH501323-05	Child	CAH	JEFFERSON HEALTHCARE	Jefferson Healthcare Sheridan Clinic	915 SHERIDAN ST	PORT TOWNSEND	WA	Active
CAH501323-06	Child	CAH	JEFFERSON HEALTHCARE	JEFFERSON COUNTY HOSPITAL DISTRICT - Oncology	834 SHERIDAN ST	PORT TOWNSEND	WA	Active
CAH501323-07	Child	CAH	JEFFERSON HEALTHCARE	JEFFERSON Healthcare Port Ludlow Clinic	89 BREAKER LN	PORT LUDLOW	WA	Active
CAH501323-08	Child	CAH	JEFFERSON HEALTHCARE	JEFFERSON COUNTY PUBLIC HOSPITAL DI - HOME HEALTH	2500 W SIMS WAY	PORT TOWNSEND	WA	Active
CAH501323-09	Child	CAH	JEFFERSON HEALTHCARE	JEFFERSON COUNTY PUBLIC HOSPITAL DI - HOSPICE	2500 W SIMS WAY	PORT TOWNSEND	WA	Active
CAH501323-10	Child	CAH	JEFFERSON HEALTHCARE	JEFFERSON HEALTHCARE Express Clinic	1274 7th St	Port Townsend	WA	Active
CAH501323-11	Child	CAH	JEFFERSON HEALTHCARE	Jefferson Healthcare OBGYN Clinic - OBGYN	1010 Sheridan St	Port Townsend	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 12:10:14 PM	8/16/2024 4:38:17 PM	8/16/2024 4:38 PM
Addresses	Billing Address	Insert	Change Request		Jefferson Healthcare Pharmacy 834 Sheridan St Port Townsend, WA 98368	5/20/2024 1:54 PM
Addresses	Shipping Address	Insert	Change Request		Jefferson Healthcare Pharmacy 834 Sheridan St Port Townsend, WA 98368	5/20/2024 1:54 PM
Contacts	Primary Contact	Update	Change Request	Nelson, Andrew Director of Pharmacy Jefferson Healthcare 3603852200-2345	Nelson, Andrew John Director of Pharmacy Jefferson Healthcare 3603852200-2345	9/18/2023 5:26 PM
Contacts	Primary Contact	Update	Profile Change Request	Nelson, Andy Director of Pharmacy Jefferson Healthcare 3603852200-2345	Nelson, Andrew Director of Pharmacy Jefferson Healthcare 3603852200-2345	9/12/2023 7:34 AM
Details	Last Recertification Date	Update	Recertification	9/15/2022 12:09:45 PM	8/23/2023 12:10:14 PM	8/23/2023 12:10 PM
Contacts	Primary Contact	Update	Change Request	Turay, Lanny DIRECTOR OF PHARMACY Jefferson Healthcare 3603852200-2301	Nelson, Andy Director of Pharmacy Jefferson Healthcare 3603852200-2345	8/2/2023 10:13 AM
Contacts	Authorizing Official	Update	Profile Change Request	Davidson, Jacob Bujacich Chief Ancillary and Support Services Officer Jefferson Healthcare 3603852200-2039	Davidson, Jacob Bujacich Chief Operating Officer Jefferson Healthcare 3603852200-2039	6/21/2023 2:37 PM
Details	Last Recertification Date	Update	Recertification	9/13/2021 5:03:51 PM	9/15/2022 12:09:45 PM	9/15/2022 12:09 PM
Details	Last Recertification Date	Update	Recertification	8/17/2020 4:06:45 PM	9/13/2021 5:03:51 PM	9/13/2021 5:03 PM
Contacts	Authorizing Official	Update	Change Request	French, Jonathan Chief Legal Officer Jefferson Healthcare 3603852200	Davidson, Jacob Bujacich Chief Ancillary and Support Services Officer Jefferson Healthcare 3603852200-2039	2/9/2021 3:31 PM
Contacts	Authorizing Official	Update	AO Change Request	Whittington, Hilary CFO Jefferson Healthcare 3603852200-2094	French, Jonathan Chief Legal Officer Jefferson Healthcare 3603852200	10/26/2020 6:50 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 9:09:10 PM	8/17/2020 4:06:45 PM	8/17/2020 4:06 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 3:40:10 PM	8/20/2019 9:09:10 PM	8/20/2019 9:09 PM
Details	Entity Subname	Update	Change Request	Jefferson Healthcare Internal Medicine, Pediatrics and Primary Care	Jefferson Healthcare Sheridan Clinic	2/20/2019 8:42 AM
Details	Last Recertification Date	Update	Recertification	11/14/2017 7:38:21 PM	8/16/2018 3:40:10 PM	8/16/2018 3:40 PM
Details	Entity Name	Update	Recertification	JEFFERSON GENERAL HOSPITAL	JEFFERSON HEALTHCARE	11/15/2017 2:45 PM
Contacts	Primary Contact	Insert	Recertification		Turay, Lanny DIRECTOR OF PHARMACY Jefferson Healthcare 3603852200-2301	11/14/2017 7:38 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/14/2017 7:38:21 PM	11/14/2017 7:38 PM
Contacts	Authorizing Official	Update		Whittington, Hilary CFO 3603852200-2094	Whittington, Hilary CFO Jefferson Healthcare 3603852200-2094	9/25/2017 3:32 PM
Contacts	Signed By	Update		Whittington, Hilary CFO 3603852200-2094	Whittington, Hilary CFO Jefferson Healthcare 3603852200-2094	9/25/2017 3:32 PM
Contacts	Authorizing Official	Insert			Whittington, Hilary CFO 3603852200-2094	7/12/2017 5:31 PM
Contacts	Signed By	Insert			Whittington, Hilary CFO 3603852200-2094	7/12/2017 5:31 PM
Addresses	Main Address	Insert			915 SHERIDAN ST PORT TOWNSEND, WA 98368-2957	8/10/2016 1:23 PM
Details	Last Recertification Date	Update			8/10/2016 12:00:00 AM	8/10/2016 1:23 PM
Details	Entity Subname	Update		South County Medical Clinic	Jefferson Healthcare Internal Medicine, Pediatrics and Primary Care	3/16/2016 8:27 AM
Dates	Participating Approval Date	Update			3/2/2016 12:00:00 AM	3/2/2016 4:25 PM
Details	State	Update		Pending	Active	3/2/2016 4:25 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	3/2/2016 4:25 PM
Details	Entity Subname	Update		JEFFERSON COUNTY PUBLIC HOSPITAL Diagnostic Imaging	South County Medical Clinic	3/1/2016 2:08 PM
Details	Entity Subname	Update		JEFFERSON COUNTY PUBLIC HOSPITAL DI	JEFFERSON COUNTY PUBLIC HOSPITAL Diagnostic Imaging	2/3/2016 11:59 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_57471	CAH501323-05	2/3/2016 11:55 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_57471	1/13/2016 12:19 PM
Details	Last Recertification Date	Insert				1/13/2016 12:19 PM
Details	Grant Number	Insert				1/13/2016 12:19 PM
Details	340B ID	Insert				1/13/2016 12:19 PM
Details	Is Authorizing Official EHB Data	Insert				1/13/2016 12:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/13/2016 12:19 PM
Details	Medicare Provider Number	Insert			501323	1/13/2016 12:19 PM
Details	Entity Name	Insert			JEFFERSON GENERAL HOSPITAL	1/13/2016 12:19 PM
Details	Program Code	Insert			CAH	1/13/2016 12:19 PM
Details	Entity Subname	Insert			JEFFERSON COUNTY PUBLIC HOSPITAL DI	1/13/2016 12:19 PM
Dates	Participating Approval Date	Insert				1/13/2016 12:19 PM
Details	State	Insert			Pending	1/13/2016 12:19 PM
Dates	Registration Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 12:19 PM
Dates	Signed By Date	Insert			1/13/2016 12:00:00 AM	1/13/2016 12:19 PM
Dates	Start Date	Insert				1/13/2016 12:19 PM
Terminations	Termination Comments	Insert				1/13/2016 12:19 PM
Terminations	Termination Date	Insert				1/13/2016 12:19 PM
Terminations	Termination Effective Date	Insert				1/13/2016 12:19 PM
Terminations	Termination Reason	Insert				1/13/2016 12:19 PM