Covered Entity Details

DSH380052F SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC. (Terminated) - information as of 6/14/2025 10:05:03 AM

Main Details

Name

SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.

Subdivision Name

SAMG ENT Ontario

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH380052F

Medicare Provider Number

380052

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/7/2016

Participating Start Date

10/1/2016

Participating Approval Date

8/23/2016

Last Recertification Date

8/30/2018

Termination Date
Termination Reason

4/1/2019
Change of covered entity type

Contacts

Authorizing Official

Saint Alphonsus Health System
Lannie Checketts, RHM CFO Idaho Oregon Region
(208) 367-7347

Primary Contact

Trinity Health
Carisa Ann McGehee, 340B Analyst
(208) 367-2087

Addresses

Street Address

SAMG ENT Ontario
1050 SW 3rd Ave Ste 1200
Ontario, OR 97914

Billing Address

Saint Alphonsus Medical Center - ONT
SAMG ENT Ontario
1050 SW 3rd Ave Ste 1200
Ontario, OR 97914

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

Saint Alphonsus Medical Center - ONT
SAMG ENT Ontario
1050 SW 3rd Ave Ste 1200
Ontario, OR 97914

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
DSH380052A	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	Oncology Ontario	1050 SW 3rd Avenue, Ste 2300	Ontario	OR	Terminated
DSH380052B	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG FHP INTERNAL MEDICINE	910 NW 16TH ST	FRUITLAND	ID	Terminated
DSH380052C	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG Ontario Surgical Services	1050 SW 3rd Ave Ste 2600	Ontario	OR	Terminated
DSH380052D	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG PODIATRY FHP	910 NW 16th Street	Fruitland	ID	Terminated
DSH380052E	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG Ontario Wound	SAMG Ontario Wound	Ontario	OR	Terminated
DSH380052F	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG ENT Ontario	SAMG ENT Ontario	Ontario	OR	Terminated
DSH380052G	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG OHP URGENT CARE / Urgent Care	840 SW 4TH AVE	ONTARIO	OR	Terminated
DSH380052H	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG OHP FAMILY MEDICINE / Family Medicine	840 SW 4TH AVE	ONTARIO	OR	Terminated
DSH380052J	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG Glycemic Ontario	351 SW 9th St	Ontario	OR	Terminated
DSH380052K	Child	DSH	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	SAMG Riverside Orthopedics - Orthopedics	910 NW 16th St	Fruitland	ID	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2019 12:00:00 AM	3/6/2019 8:13 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	3/6/2019 8:13 AM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2019 12:00:00 AM	3/6/2019 8:13 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2019 12:00:00 AM	3/6/2019 8:13 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	3/6/2019 8:13 AM
Contacts	Primary Contact	Update	Change Request	Phillips, Mark AVP Prof Services/Director SAHS Pharmacy Saint Alphonsus Health System 2083674943	McGehee, Carisa Ann 340B Analyst Trinity Health 2083672087	1/21/2019 3:51 PM
Details	Last Recertification Date	Update	Recertification	11/3/2017 12:42:54 PM	8/30/2018 12:41:21 PM	8/30/2018 12:41 PM
Details	Entity Name	Update	Recertification	SAINT ALPHONSUS MEDICAL CENTER - ONT	SAINT ALPHONSUS MEDICAL CENTER - ONTARIO INC.	11/3/2017 12:43 PM
Details	Last Recertification Date	Update	Recertification		11/3/2017 12:42:54 PM	11/3/2017 12:42 PM
Contacts	Primary Contact	Update	New Registration	Phillips, Mark AVP Prof Services/Director SAHS Pharmacy 2083674943	Phillips, Mark AVP Prof Services/Director SAHS Pharmacy Saint Alphonsus Health System 2083674943	10/13/2017 9:51 AM
Contacts	Authorizing Official	Update		Checketts, Lannie RHM CFO Idaho Oregon Region 2083677347	Checketts, Lannie RHM CFO Idaho Oregon Region Saint Alphonsus Health System 2083677347	10/11/2017 12:18 PM
Contacts	Signed By	Insert			Fry, Kenneth VP Finance 2083673445	8/9/2017 11:15 AM
Contacts	Authorizing Official	Insert			Checketts, Lannie RHM CFO Idaho Oregon Region 2083677347	8/4/2017 10:49 AM
Contacts	Primary Contact	Update		Kudrna, Dale Director of Pharmacy 5418817185	Phillips, Mark AVP Prof Services/Director SAHS Pharmacy 2083674943	8/4/2017 10:49 AM
Addresses	Main Address	Insert			SAMG ENT Ontario 1050 SW 3rd Ave Ste 1200 Ontario, OR 97914	2/15/2017 2:54 PM
Addresses	Billing Address	Insert			Saint Alphonsus Medical Center - ONT SAMG ENT Ontario 1050 SW 3rd Ave Ste 1200 Ontario, OR 97914	2/15/2017 2:54 PM
Addresses	Shipping Address	Insert			Saint Alphonsus Medical Center - ONT SAMG ENT Ontario 1050 SW 3rd Ave Ste 1200 Ontario, OR 97914	2/15/2017 2:54 PM
Contacts	Primary Contact	Insert			Kudrna, Dale Director of Pharmacy 5418817185	8/23/2016 1:20 PM
Dates	Participating Approval Date	Update			8/23/2016 12:00:00 AM	8/23/2016 1:20 PM
Details	State	Update		Pending	Active	8/23/2016 1:20 PM
Dates	Start Date	Update			10/1/2016 12:00:00 AM	8/23/2016 1:20 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_71103	DSH380052F	7/19/2016 2:50 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_71103	7/7/2016 12:04 PM
Details	Last Recertification Date	Insert				7/7/2016 12:04 PM
Details	Grant Number	Insert				7/7/2016 12:04 PM
Details	340B ID	Insert				7/7/2016 12:04 PM
Details	Is Authorizing Official EHB Data	Insert				7/7/2016 12:04 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/7/2016 12:04 PM
Details	Medicare Provider Number	Insert			380052	7/7/2016 12:04 PM
Details	Entity Name	Insert			SAINT ALPHONSUS MEDICAL CENTER - ONT	7/7/2016 12:04 PM
Details	Program Code	Insert			DSH	7/7/2016 12:04 PM
Details	Entity Subname	Insert			SAMG ENT Ontario	7/7/2016 12:04 PM
Dates	Participating Approval Date	Insert				7/7/2016 12:04 PM
Details	State	Insert			Pending	7/7/2016 12:04 PM
Dates	Registration Date	Insert			7/7/2016 12:00:00 AM	7/7/2016 12:04 PM
Dates	Signed By Date	Insert			7/7/2016 12:00:00 AM	7/7/2016 12:04 PM
Dates	Start Date	Insert				7/7/2016 12:04 PM
Terminations	Termination Comments	Insert				7/7/2016 12:04 PM
Terminations	Termination Date	Insert				7/7/2016 12:04 PM
Terminations	Termination Effective Date	Insert				7/7/2016 12:04 PM
Terminations	Termination Reason	Insert				7/7/2016 12:04 PM