Covered Entity Details

CAH051325-01 ADVENTIST HEALTH MENDOCINO COAST (Active) - information as of 4/29/2025 12:35:42 AM

Main Details

Name

ADVENTIST HEALTH MENDOCINO COAST

Subdivision Name

AH Fort Bragg Mendocino Coast RHC

Type

Critical Access Hospital

Rural

340B ID

CAH051325-01

Medicare Provider Number

051325

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/10/2016

Participating Start Date

1/1/2017

Participating Approval Date

10/17/2016

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

721 River Drive
Suites A, B and C
Fort Bragg, CA 95437

Billing Address

ADVENTIST HEALTH MENDOCINO COAST
700 River Drive
Fort Bragg, CA 95437

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		1124220249,1538113725

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH051325-01	Child	CAH	ADVENTIST HEALTH MENDOCINO COAST	AH Fort Bragg Mendocino Coast RHC	721 River Drive	Fort Bragg	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 12:05:21 PM	8/18/2024 7:12:48 PM	8/18/2024 7:12 PM
Addresses	Main Address	Update	Change Request	721 River Drive Fort Bragg, CA 95437	721 River Drive Suites A, B and C Fort Bragg, CA 95437	1/18/2024 2:55 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1124220249 (CA)		1/18/2024 2:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1538113725	1/18/2024 2:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	1/18/2024 2:55 PM
Details	Entity Subname	Update	Change Request	North Coast Family Health Center	AH Fort Bragg Mendocino Coast RHC	1/18/2024 2:55 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 6:45 AM
Contacts	Primary Contact	Update	Recertification	Leister, Lois Faith Clinical Pharmacy Services Director Adventist Health Mendocino Coast 7079614677	Dolmage, Tracy Pharmacy Analyst Adventist Health Ukiah Valley 7074637633	9/6/2023 12:05 PM
Details	Last Recertification Date	Update	Recertification	9/9/2022 5:57:56 PM	9/6/2023 12:05:21 PM	9/6/2023 12:05 PM
Contacts	Authorizing Official	Update	Change Request	Howe, Judson Network President Adventist Health Ukiah Valley 7074675352	Shepardson, Dean Finance Officer Adventist Health North Coast Network 7074635357	5/18/2023 7:31 AM
Contacts	Authorizing Official	Update	Change Request	Tetz, Warren Lee Finance Officer Adventist Health Ukiah Valley 7074563001	Howe, Judson Network President Adventist Health Ukiah Valley 7074675352	1/24/2023 1:09 PM
Details	Last Recertification Date	Update	Recertification	8/19/2021 4:54:55 PM	9/9/2022 5:57:56 PM	9/9/2022 5:57 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	3/24/2022 2:13 PM
Details	Last Recertification Date	Update	Recertification	9/9/2020 1:56:58 PM	8/19/2021 4:54:55 PM	8/19/2021 4:54 PM
Addresses	Shipping Address	Delete	Change Request	Mendocino Coast District Hospital 700 River Driver Fort Bragg, CA 95437		10/13/2020 6:55 AM
Addresses	Billing Address	Update	Change Request	Mendocino Coast District Hospital 700 River Drive Fort Bragg, CA 95437	Adventist Health Mendocino Coast 700 River Drive Fort Bragg, CA 95437	10/13/2020 6:55 AM
Contacts	Primary Contact	Update	Change Request	Leister, Lois Faith Clinical Pharmacy Services Director Adventist Health Mendocino Coast 7079614677	Leister, Lois Faith Clinical Pharmacy Services Director Adventist Health Mendocino Coast 7079614677	10/13/2020 6:55 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/9/2020 1:56 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 6:48:12 PM	9/9/2020 1:56:58 PM	9/9/2020 1:56 PM
Contacts	Authorizing Official	Update	Change Request	Howe, Judson CFO Adventist Health Howard Memorial 7074563001	Parker, Bessant Medical Officer Adventist Health Howard Memorial 7074637693	8/14/2020 7:51 AM
Contacts	Primary Contact	Update	Profile Change Request	Leister, Lois Faith Pharmacy Manager Mendocino Coast District Hospital 7079614677	Leister, Lois Faith Clinical Pharmacy Services Director Adventist Health Mendocino Coast 7079614677	8/12/2020 1:54 PM
Details	Entity Name	Update	Change Request	MENDOCINO COAST DISTRICT HOSPITAL	ADVENTIST HEALTH MENDOCINO COAST	7/23/2020 12:52 PM
Addresses	Shipping Address	Insert	Change Request		Mendocino Coast District Hospital 700 River Driver Fort Bragg, CA 95437	6/3/2020 1:11 PM
Contacts	Authorizing Official	Update	Change Request	Allen, Wayne C. CEO Mendocino Coast District Hospital 7079614630	Howe, Judson CFO Adventist Health Howard Memorial 7074563001	5/21/2020 6:57 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 3:20:11 PM	8/22/2019 6:48:12 PM	8/22/2019 6:48 PM
Contacts	Authorizing Official	Update	Change Request	Ellis, Mike CEO/CFO Mendocino Coast District Hospital 7079611234-610	Allen, Wayne C. CEO Mendocino Coast District Hospital 7079614630	4/26/2019 2:09 PM
Contacts	Authorizing Official	Update	Change Request	Edwards, Bob S. CEO Mendocino Coast District Hospitl 7079614611	Ellis, Mike CEO/CFO Mendocino Coast District Hospital 7079611234-610	2/20/2019 8:37 AM
Details	Last Recertification Date	Update	Recertification	11/13/2017 4:25:14 PM	9/6/2018 3:20:11 PM	9/6/2018 3:20 PM
Details	Last Recertification Date	Update	Recertification		11/13/2017 4:25:14 PM	11/13/2017 4:25 PM
Contacts	Primary Contact	Update	Recertification	Leister, Lois Pharmacy Manager Mendocino Coast District Hospital 7079614677	Leister, Lois Faith Pharmacy Manager Mendocino Coast District Hospital 7079614677	11/13/2017 4:23 PM
Contacts	Primary Contact	Update		Leister, Lois Pharmacy Manager 7079614677	Leister, Lois Pharmacy Manager Mendocino Coast District Hospital 7079614677	9/27/2017 12:55 PM
Contacts	Authorizing Official	Update		Edwards, Bob S. CEO 7079614611	Edwards, Bob S. CEO Mendocino Coast District Hospitl 7079614611	9/27/2017 11:29 AM
Contacts	Signed By	Update		Edwards, Bob S. CEO 7079614611	Edwards, Bob S. CEO Mendocino Coast District Hospitl 7079614611	9/27/2017 11:29 AM
Addresses	Main Address	Insert			721 River Drive Fort Bragg, CA 95437	3/22/2017 1:41 PM
Addresses	Billing Address	Insert			Mendocino Coast District Hospital 700 River Drive Fort Bragg, CA 95437	3/22/2017 1:41 PM
Contacts	Primary Contact	Insert			Leister, Lois Pharmacy Manager 7079614677	3/22/2017 1:41 PM
Contacts	Authorizing Official	Insert			Edwards, Bob S. CEO 7079614611	3/22/2017 1:41 PM
Contacts	Signed By	Insert			Edwards, Bob S. CEO 7079614611	3/22/2017 1:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/22/2017 1:41 PM
Medicaid Billing	Medicaid: Number	Insert			1124220249	3/22/2017 1:41 PM
Medicaid Billing	Medicaid: State	Insert			CA	3/22/2017 1:41 PM
Medicaid Billing	NPI: Number	Update		1538113725	1124220249	3/22/2017 1:41 PM
Dates	Participating Approval Date	Update			10/17/2016 12:00:00 AM	10/17/2016 1:19 PM
Details	State	Update		Pending	Active	10/17/2016 1:19 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	10/17/2016 1:19 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_72770	CAH051325-01	10/11/2016 11:30 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_72770	10/10/2016 2:07 PM
Medicaid Billing	NPI: Number	Insert			1538113725	10/10/2016 2:07 PM
Details	Last Recertification Date	Insert				10/10/2016 2:07 PM
Details	Grant Number	Insert				10/10/2016 2:07 PM
Details	340B ID	Insert				10/10/2016 2:07 PM
Details	Is Authorizing Official EHB Data	Insert				10/10/2016 2:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/10/2016 2:07 PM
Details	Medicare Provider Number	Insert			051325	10/10/2016 2:07 PM
Details	Entity Name	Insert			MENDOCINO COAST DISTRICT HOSPITAL	10/10/2016 2:07 PM
Details	Program Code	Insert			CAH	10/10/2016 2:07 PM
Details	Entity Subname	Insert			North Coast Family Health Center	10/10/2016 2:07 PM
Dates	Participating Approval Date	Insert				10/10/2016 2:07 PM
Details	State	Insert			Pending	10/10/2016 2:07 PM
Dates	Registration Date	Insert			10/10/2016 12:00:00 AM	10/10/2016 2:07 PM
Dates	Signed By Date	Insert			10/10/2016 12:00:00 AM	10/10/2016 2:07 PM
Dates	Start Date	Insert				10/10/2016 2:07 PM
Terminations	Termination Comments	Insert				10/10/2016 2:07 PM
Terminations	Termination Date	Insert				10/10/2016 2:07 PM
Terminations	Termination Effective Date	Insert				10/10/2016 2:07 PM
Terminations	Termination Reason	Insert				10/10/2016 2:07 PM