Covered Entity Details

PED503301-02 Mary Bridge Children's Hospital and Health Center (Active) - information as of 4/23/2025 10:51:06 PM

Main Details

Name

Mary Bridge Children's Hospital and Health Center

Subdivision Name

Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Pediatric Infusion Clinic

Type

Children's Hospital

Rural

340B ID

PED503301-02

Medicare Provider Number

503301

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2016

Participating Start Date

7/1/2016

Participating Approval Date

4/22/2016

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

MultiCare Health System
Timothy Wayne Lynch, Sr. VP, Chief Administrative Officer
(253) 403-2824

Primary Contact

MultiCare Health System
Cindy Wilson, Assistant Vice President - Pharmacy Compliance
(253) 403-2822

Addresses

Street Address

311 South L Street
Tacoma, WA 98405

Billing Address

MultiCare Health System
PO Box 5299
MS 1313-5-AP
Tacoma, WA 98415-0299

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
WA	1043667	1306952726,1164536025

Shipping Addresses

Shipping Address 1

Mary Bridge Retail Clinic Pharmacy
311 South L Street
Tacoma, WA 98405

Shipping Address 2

Mary Bridge Ambulatory Clinic Pharmacy
311 South L Street
Tacoma, WA 98405

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
PED503301-01	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Clinical Neurophysiology	1112 6th Avenue, Suite 100	Tacoma	WA	Active
PED503301-02	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Pediatric Infusion Clinic	311 South L Street	Tacoma	WA	Active
PED503301-03	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Echo	311 South L Street	Tacoma	WA	Active
PED503301-04	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Physical Medicine Rehab	316 MLK Jr Way	Tacoma	WA	Active
PED503301-05	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Radiology	311 South L Street	Tacoma	WA	Active
PED503301-06	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Cardio Thoracic	311 South L Street	Tacoma	WA	Active
PED503301-07	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Orthopedic Clinic	311 South L Street	Tacoma	WA	Active
PED503301-08	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Craniofacial Clinic	311 South L Street	Tacoma	WA	Active
PED503301-09	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Respiratory Clinic	311 South L Street	Tacoma	WA	Active
PED503301-10	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Peds Surgical Services	311 South L Street	Tacoma	WA	Active
PED503301-11	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Peds Neurology Services	1112 6th Ave, Suite 100	Tacoma	WA	Active
PED503301-12	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Hematology/Oncology	311 South L Street	Tacoma	WA	Active
PED503301-13	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Cystic Fibrosis	311 South L Street	Tacoma	WA	Active
PED503301-14	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Children's Ambulatory Specialty Clinic / Mary Bridge Tacoma Gastro Lab	311 South L Street	Tacoma	WA	Active
PED503301-15	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma Gastro Clinic	311 South L Street	Tacoma	WA	Active
PED503301-16	Child	PED	Mary Bridge Children's Hospital and Health Center	Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Tacoma ENT Clinic	316 MLK Jr Way, Suite 304	Tacoma	WA	Active
PED503301-17	Child	PED	Mary Bridge Children's Hospital and Health Center	MB TAC PEDS PSYCH SVCS - MB TAC PEDS PSYCH SVCS	1220 Division Ave	TACOMA	WA	Active
PED503301-18	Child	PED	Mary Bridge Children's Hospital and Health Center	MB SEDATION SERVICES - MB SEDATION SERVICES	317 Martin Luther King Jr Way	TACOMA	WA	Terminated
PED503301-19	Child	PED	Mary Bridge Children's Hospital and Health Center	MB TAC NEPHROLOGY CLINIC - MB TAC NEPHROLOGY CLINIC	311 South "L" Street	TACOMA	WA	Terminated
PED503301-20	Child	PED	Mary Bridge Children's Hospital and Health Center	MB TAC ENDOCRINE CLINIC - MB TAC ENDOCRINE CLINIC	311 South "L" Street	TACOMA	WA	Active
PED503301-21	Child	PED	Mary Bridge Children's Hospital and Health Center	MB TAC DIABETES SERVICES - MB TAC DIABETES SERVICES	311 South "L" Street	TACOMA	WA	Terminated
PED503301-22	Child	PED	Mary Bridge Children's Hospital and Health Center	MB TAC RHEUMATOLOGY - MB TAC RHEUMATOLOGY	311 South "L" Street	TACOMA	WA	Active
PED503301-23	Child	PED	Mary Bridge Children's Hospital and Health Center	MB TAC DBP - MB TAC DBP	1220 Division Ave	TACOMA	WA	Terminated
PED503301-24	Child	PED	Mary Bridge Children's Hospital and Health Center	MB TAC GENETICS CLINIC - Genetics	311 South "L" Street	TACOMA	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 12:07:29 PM	8/18/2024 7:45:41 PM	8/18/2024 7:45 PM
Details	Last Recertification Date	Update	Recertification	9/17/2022 4:00:23 PM	9/5/2023 12:07:29 PM	9/5/2023 12:07 PM
Contacts	Authorizing Official	Update	AO Change Request	Chang, Florence President MULTICARE HEALTH SYSTEM 2534037355	Lynch, Timothy Wayne Sr. VP, Chief Administrative Officer MultiCare Health System 2534032824	11/7/2022 8:34 AM
Details	Last Recertification Date	Update	Recertification	8/31/2021 2:19:35 PM	9/17/2022 4:00:23 PM	9/17/2022 4:00 PM
Contacts	Authorizing Official	Update	Profile Change Request	Chang, Florence Executive Vice President MULTICARE HEALTH SYSTEM 2534037355	Chang, Florence President MULTICARE HEALTH SYSTEM 2534037355	4/18/2022 7:16 AM
Contacts	Signed By	Update	Profile Change Request	Chang, Florence Executive Vice President MULTICARE HEALTH SYSTEM 2534037355	Chang, Florence President MULTICARE HEALTH SYSTEM 2534037355	4/18/2022 7:16 AM
Contacts	Primary Contact	Update	Profile Change Request	Wilson, Cindy Executive Director Pharmacy Compliance MultiCare Health System 2534032822	Wilson, Cindy Assistant Vice President - Pharmacy Compliance MultiCare Health System 2534032822	4/15/2022 12:38 PM
Contacts	Primary Contact	Update	Profile Change Request	Wilson, Cindy Director Pharmacy Compliance MultiCare Health System 2534032822	Wilson, Cindy Executive Director Pharmacy Compliance MultiCare Health System 2534032822	12/1/2021 11:55 AM
Contacts	Primary Contact	Update	Change Request	Campanella, Maria Director 340B Program MultiCare Health System 2534038314	Wilson, Cindy Director Pharmacy Compliance MultiCare Health System 2534032822	11/3/2021 8:14 AM
Addresses	Billing Address	Update	Recertification	MultiCare Health System 737 South Fawcett MS: 737-4-AP Tacoma, WA 98415-0299	MultiCare Health System PO Box 5299 MS 1313-5-AP Tacoma, WA 98415-0299	8/31/2021 2:19 PM
Contacts	Primary Contact	Update	Recertification	Scheer, LeeAnn Director of Pharmacy Supply Chain and 340B Multicare Health System 5127898341	Campanella, Maria Director 340B Program MultiCare Health System 2534038314	8/31/2021 2:19 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 1:47:32 AM	8/31/2021 2:19:35 PM	8/31/2021 2:19 PM
Contacts	Primary Contact	Update	Profile Change Request	Scheer, LeeAnn Director of Pharmacy Supply Chain and 340B Multicare Health System 2534032934	Scheer, LeeAnn Director of Pharmacy Supply Chain and 340B Multicare Health System 5127898341	12/4/2020 7:15 PM
Medicaid Billing	NPI: State	Update	Recertification		WA	9/9/2020 1:47 AM
Medicaid Billing	NPI: State	Update	Recertification		WA	9/9/2020 1:47 AM
Details	Last Recertification Date	Update	Recertification	9/9/2019 12:48:03 AM	9/9/2020 1:47:32 AM	9/9/2020 1:47 AM
Addresses	Billing Address	Update	Change Request	MultiCare Health System PO Box 5299 MS: 737-4-AP Tacoma, WA 98415-0299	MultiCare Health System 737 South Fawcett MS: 737-4-AP Tacoma, WA 98415-0299	5/20/2020 1:31 AM
Contacts	Primary Contact	Update	Change Request	Johnson, Jae Pharmacy 340B Analyst Multicare Health Systems 2534035541	Scheer, LeeAnn Director of Pharmacy Supply Chain and 340B Multicare Health System 2534032934	3/10/2020 2:03 PM
Contacts	Primary Contact	Update	Change Request	Aflatooni, Vafa Director Pharmacy Supply Chain and 340B MultiCare Health System 2534032082	Johnson, Jae Pharmacy 340B Analyst Multicare Health Systems 2534035541	11/25/2019 1:00 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1598701617 ( )		11/8/2019 12:23 AM
Medicaid Billing	Medicaid: Number	Update	Recertification	503301-00	1043667	9/9/2019 12:48 AM
Details	Last Recertification Date	Update	Recertification	8/25/2018 10:39:51 PM	9/9/2019 12:48:03 AM	9/9/2019 12:48 AM
Contacts	Primary Contact	Update	Profile Change Request	Aflatooni, Vafa Pharmacy Manager MultiCare Health System 2534032082	Aflatooni, Vafa Director Pharmacy Supply Chain and 340B MultiCare Health System 2534032082	5/15/2019 4:37 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598701617	12/13/2018 1:59 AM
Details	Last Recertification Date	Update	Recertification	11/5/2017 8:19:07 PM	8/25/2018 10:39:51 PM	8/25/2018 10:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/18/2018 1:34 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		503301-00	1/18/2018 1:34 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	1/18/2018 1:34 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1306952726	1/18/2018 1:34 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1164536025	1/18/2018 1:34 AM
Contacts	Primary Contact	Update	Change Request	Rowe, Tom Director, Phamacy Acute Care MultiCare Health System 2534031629	Aflatooni, Vafa Pharmacy Manager MultiCare Health System 2534032082	1/18/2018 1:34 AM
Details	Last Recertification Date	Update	Recertification	10/25/2017 8:56:15 AM	11/5/2017 8:19:07 PM	11/5/2017 8:19 PM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	10/25/2017 8:56:15 AM	10/25/2017 8:56 AM
Contacts	Primary Contact	Update	Profile Change Request	Rowe, Tom Pharmacy Clinical Manager MultiCare Health System 2534031629	Rowe, Tom Director, Phamacy Acute Care MultiCare Health System 2534031629	10/18/2017 8:53 PM
Contacts	Primary Contact	Update		Rowe, Tom Pharmacy Clinical Manager 2534031629	Rowe, Tom Pharmacy Clinical Manager MultiCare Health System 2534031629	10/18/2017 8:49 PM
Contacts	Authorizing Official	Update		Chang, Florence Executive Vice President 2534037355	Chang, Florence Executive Vice President MULTICARE HEALTH SYSTEM 2534037355	10/9/2017 5:21 PM
Contacts	Signed By	Update		Chang, Florence Executive Vice President 2534037355	Chang, Florence Executive Vice President MULTICARE HEALTH SYSTEM 2534037355	10/9/2017 5:21 PM
Contacts	Authorizing Official	Insert			Chang, Florence Executive Vice President 2534037355	2/15/2017 11:03 AM
Contacts	Signed By	Insert			Chang, Florence Executive Vice President 2534037355	2/15/2017 11:03 AM
Contacts	Primary Contact	Insert			Rowe, Tom Pharmacy Clinical Manager 2534031629	9/7/2016 5:43 PM
Addresses	Main Address	Insert			311 South L Street Tacoma, WA 98405	8/16/2016 7:15 AM
Details	Last Recertification Date	Update			8/16/2016 12:00:00 AM	8/16/2016 7:15 AM
Addresses	Billing Address	Insert			MultiCare Health System PO Box 5299 MS: 737-4-AP Tacoma, WA 98415-0299	4/22/2016 3:55 PM
Addresses	Shipping Address	Insert			Mary Bridge Ambulatory Clinic Pharmacy 311 South L Street Tacoma, WA 98405	4/22/2016 3:55 PM
Addresses	Shipping Address	Insert			Mary Bridge Retail Clinic Pharmacy 311 South L Street Tacoma, WA 98405	4/22/2016 3:55 PM
Dates	Participating Approval Date	Update			4/22/2016 12:00:00 AM	4/22/2016 3:34 PM
Details	State	Update		Pending	Active	4/22/2016 3:34 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	4/22/2016 3:34 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_60634	PED503301-02	4/21/2016 3:40 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_60634	4/15/2016 3:50 PM
Details	Last Recertification Date	Insert				4/15/2016 3:50 PM
Details	Grant Number	Insert				4/15/2016 3:50 PM
Details	340B ID	Insert				4/15/2016 3:50 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2016 3:50 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2016 3:50 PM
Details	Medicare Provider Number	Insert			503301	4/15/2016 3:50 PM
Details	Entity Name	Insert			Mary Bridge Children's Hospital and Health Center	4/15/2016 3:50 PM
Details	Program Code	Insert			PED	4/15/2016 3:50 PM
Details	Entity Subname	Insert			Mary Bridge Ambulatory Specialty Clinic / Mary Bridge Pediatric Infusion Clinic	4/15/2016 3:50 PM
Dates	Participating Approval Date	Insert				4/15/2016 3:50 PM
Details	State	Insert			Pending	4/15/2016 3:50 PM
Dates	Registration Date	Insert			4/15/2016 12:00:00 AM	4/15/2016 3:50 PM
Dates	Signed By Date	Insert			4/15/2016 12:00:00 AM	4/15/2016 3:50 PM
Dates	Start Date	Insert				4/15/2016 3:50 PM
Terminations	Termination Comments	Insert				4/15/2016 3:50 PM
Terminations	Termination Date	Insert				4/15/2016 3:50 PM
Terminations	Termination Effective Date	Insert				4/15/2016 3:50 PM
Terminations	Termination Reason	Insert				4/15/2016 3:50 PM