Covered Entity Details

DSH050129E ST. BERNARDINE MEDICAL CENTER (Terminated) - information as of 6/3/2025 12:05:45 PM

Main Details

Name

ST. BERNARDINE MEDICAL CENTER

Subdivision Name

Op Surgery

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050129E

Medicare Provider Number

050129

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/13/2016

Participating Start Date

1/1/2017

Participating Approval Date

11/4/2016

Last Recertification Date

8/21/2019

Termination Date
Termination Reason

7/1/2020
Business decision by the Covered Entity

Contacts

Authorizing Official

St Bernardines
Paul Steinke, CFO
(909) 881-7196

Primary Contact

St. Bernardine Medical Center
Jason M Vest, Director of Pharmacy
(909) 881-4473

Addresses

Street Address

401 Highland Avenue
2nd Floor
San Bernardino, CA 92404

Billing Address

Dignity Health Accounts Payable
3033 N. 3rd Ave
Phoenix, AZ 85013

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
		1689769911

Shipping Addresses

Shipping Address 1

St. Bernardine Medical Center
2101 N. Waterman Ave
San Bernardino, CA 92404

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
DSH050129A	Child	DSH	ST. BERNARDINE MEDICAL CENTER	Urgent Care Highland	27925 Highland Avenue	Highland	CA	Active
DSH050129B	Child	DSH	ST. BERNARDINE MEDICAL CENTER	Urgent Care Fontana	17051 Sierra Lakes Parkway Suite #102	Fontana	CA	Active
DSH050129C	Child	DSH	ST. BERNARDINE MEDICAL CENTER	CACU	401 Highland Avenue	San Bernardino	CA	Terminated
DSH050129D	Child	DSH	ST. BERNARDINE MEDICAL CENTER	OP Imaging	401 Highland Avenue	San Bernardino	CA	Terminated
DSH050129E	Child	DSH	ST. BERNARDINE MEDICAL CENTER	Op Surgery	401 Highland Avenue	San Bernardino	CA	Terminated
DSH050129F	Child	DSH	ST. BERNARDINE MEDICAL CENTER	Wound Healing Center	27925 Highland Ave	Highland	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Vest, Jason M Pharmacy Manager St. Bernardine Medical Center 9098813577-4745	Vest, Jason M Director of Pharmacy St. Bernardine Medical Center 9098814473	9/8/2021 4:57 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/21/2020 12:00:00 AM	5/26/2020 12:33 PM
Details	State	Update	Termination Request	Active	To Be Terminated	5/26/2020 12:33 PM
Terminations	Termination Date	Update	Termination Request		7/1/2020 12:00:00 AM	5/26/2020 12:33 PM
Terminations	Termination Effective Date	Update	Termination Request		5/22/2020 12:00:00 AM	5/26/2020 12:33 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	5/26/2020 12:33 PM
Details	Last Recertification Date	Update	Recertification	9/11/2018 2:27:53 PM	8/21/2019 1:40:03 PM	8/21/2019 1:40 PM
Contacts	Authorizing Official	Update	Change Request	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-7196	Steinke, Paul CFO St Bernardines 9098817196	3/5/2019 7:53 AM
Contacts	Primary Contact	Update	Change Request	Gelios, Dondreia Director Pharmacy DignityHealth St. Bernardine Medical Center 9098814473	Vest, Jason M Pharmacy Manager St. Bernardine Medical Center 9098813577-4745	1/8/2019 3:49 PM
Contacts	Primary Contact	Update	Recertification	Vest, Jason M Pharmacy Manager St. Bernardine Medical Center 9098813577-4745	Gelios, Dondreia Director Pharmacy DignityHealth St. Bernardine Medical Center 9098814473	9/11/2018 2:27 PM
Details	Last Recertification Date	Update	Recertification	11/10/2017 2:26:08 PM	9/11/2018 2:27:53 PM	9/11/2018 2:27 PM
Details	Last Recertification Date	Update	Recertification	10/24/2017 11:01:03 AM	11/10/2017 2:26:08 PM	11/10/2017 2:26 PM
Contacts	Authorizing Official	Update	Recertification	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-7196	10/24/2017 1:13 PM
Contacts	Signed By	Update	Recertification	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-7196	10/24/2017 1:13 PM
Contacts	Authorizing Official	Update	Profile Change Request	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-7196	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196	10/24/2017 1:06 PM
Contacts	Signed By	Update	Profile Change Request	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-7196	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196	10/24/2017 1:06 PM
Contacts	Authorizing Official	Update	Profile Change Request	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-9097711813	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-7196	10/24/2017 1:01 PM
Contacts	Signed By	Update	Profile Change Request	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-9097711813	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-7196	10/24/2017 1:01 PM
Contacts	Primary Contact	Update	Profile Change Request	Vest, Jason Pharmacy Manager St. Bernardine Medical Center 9098813577-4745	Vest, Jason M Pharmacy Manager St. Bernardine Medical Center 9098813577-4745	10/24/2017 12:49 PM
Contacts	Authorizing Official	Update	Profile Change Request	Way, Harold F CFO St. Bernardine Medical Center 9098817196-9097711813	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-9097711813	10/24/2017 12:41 PM
Contacts	Signed By	Update	Profile Change Request	Way, Harold F CFO St. Bernardine Medical Center 9098817196-9097711813	Way, Harold F VP Finance & CFO St. Bernardine Medical Center 9098817196-9097711813	10/24/2017 12:41 PM
Contacts	Authorizing Official	Update	Profile Change Request	Way, Harold F CFO St. Bernardine Medical Center 5624919929-9098817196	Way, Harold F CFO St. Bernardine Medical Center 9098817196-9097711813	10/24/2017 12:41 PM
Contacts	Signed By	Update	Profile Change Request	Way, Harold F CFO St. Bernardine Medical Center 5624919929-9098817196	Way, Harold F CFO St. Bernardine Medical Center 9098817196-9097711813	10/24/2017 12:41 PM
Details	Last Recertification Date	Update	Recertification		10/24/2017 11:01:03 AM	10/24/2017 11:01 AM
Contacts	Authorizing Official	Update		Way, Harold CFO 5624919929	Way, Harold F CFO St. Bernardine Medical Center 5624919929-9098817196	10/9/2017 2:51 PM
Contacts	Signed By	Update		Way, Harold CFO 5624919929	Way, Harold F CFO St. Bernardine Medical Center 5624919929-9098817196	10/9/2017 2:51 PM
Contacts	Primary Contact	Update	Profile Change Request	Vest, Jason Interim Pharmacy Manager St. Bernardine Medical Center 9098814745-4745	Vest, Jason Pharmacy Manager St. Bernardine Medical Center 9098813577-4745	10/4/2017 3:56 PM
Contacts	Primary Contact	Update		Vest, Jason Interim Pharmacy Manager 9098814745	Vest, Jason Interim Pharmacy Manager St. Bernardine Medical Center 9098814745-4745	10/4/2017 3:54 PM
Contacts	Authorizing Official	Insert			Way, Harold CFO 5624919929	3/20/2017 11:42 AM
Contacts	Signed By	Insert			Way, Harold CFO 5624919929	3/20/2017 11:42 AM
Addresses	Main Address	Insert			401 Highland Avenue 2nd Floor San Bernardino, CA 92404	11/4/2016 1:12 PM
Addresses	Billing Address	Insert			Dignity Health Accounts Payable 3033 N. 3rd Ave Phoenix, AZ 85013	11/4/2016 1:12 PM
Addresses	Shipping Address	Insert			St. Bernardine Medical Center 2101 N. Waterman Ave San Bernardino, CA 92404	11/4/2016 1:12 PM
Contacts	Primary Contact	Insert			Vest, Jason Interim Pharmacy Manager 9098814745	11/4/2016 1:12 PM
Dates	Participating Approval Date	Update			11/4/2016 12:00:00 AM	11/4/2016 1:12 PM
Details	State	Update		Pending	Active	11/4/2016 1:12 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	11/4/2016 1:12 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_73118	DSH050129E	11/3/2016 12:27 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_73118	10/13/2016 4:49 PM
Medicaid Billing	NPI: Number	Insert			1689769911	10/13/2016 4:49 PM
Details	Last Recertification Date	Insert				10/13/2016 4:49 PM
Details	Grant Number	Insert				10/13/2016 4:49 PM
Details	340B ID	Insert				10/13/2016 4:49 PM
Details	Is Authorizing Official EHB Data	Insert				10/13/2016 4:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/13/2016 4:49 PM
Details	Medicare Provider Number	Insert			050129	10/13/2016 4:49 PM
Details	Entity Name	Insert			ST. BERNARDINE MEDICAL CENTER	10/13/2016 4:49 PM
Details	Program Code	Insert			DSH	10/13/2016 4:49 PM
Details	Entity Subname	Insert			Op Surgery	10/13/2016 4:49 PM
Dates	Participating Approval Date	Insert				10/13/2016 4:49 PM
Details	State	Insert			Pending	10/13/2016 4:49 PM
Dates	Registration Date	Insert			10/13/2016 12:00:00 AM	10/13/2016 4:49 PM
Dates	Signed By Date	Insert			10/13/2016 12:00:00 AM	10/13/2016 4:49 PM
Dates	Start Date	Insert				10/13/2016 4:49 PM
Terminations	Termination Comments	Insert				10/13/2016 4:49 PM
Terminations	Termination Date	Insert				10/13/2016 4:49 PM
Terminations	Termination Effective Date	Insert				10/13/2016 4:49 PM
Terminations	Termination Reason	Insert				10/13/2016 4:49 PM