Covered Entity Details

DSH500150V LEGACY SALMON CREEK HOSPITAL (Active) - information as of 6/17/2025 3:02:12 AM

Main Details

Name

LEGACY SALMON CREEK HOSPITAL

Subdivision Name

Legacy Salmon Creek Oncology at the Vancouver Clinic / TVC Infusion Clinic 600-3550

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500150V

Medicare Provider Number

500150

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/11/2017

Participating Start Date

1/1/2018

Participating Approval Date

11/21/2017

Last Recertification Date

9/2/2024

Contacts

Authorizing Official

Legacy Health
Kecia Kelly, SVP Chief Nursing Officer
(503) 415-5199

Primary Contact

Legacy Health
Elena Valcarlos, Pharmacy Systems Manager
(503) 413-7764

Addresses

Street Address

700 NE 87th Ave
360
Vancouver, WA 98664

Billing Address
Same as Street Address

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
OR	027978	1700809829
WA	1016776	1700809829

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
DSH500150B	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Computed Tomography / CT Scan 600-3516	2101 NE 139th St	Vancouver	WA	Active
DSH500150C	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Rehabilitation / Rehab 600-3612	2121 NE 139th Street	Vancouver	WA	Active
DSH500150D	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Medication Management Services / Anticoagulation Clinic 600-3719	2121 NE 139th St	Vancouver	WA	Active
DSH500150E	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Fishers Landing	16703 SE McGillivray Blvd, Suite 120	Vancouver	WA	Terminated
DSH500150F	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Radiology / Radiology-Diagnostic 600-3512	2101 NE 139th St	Vancouver	WA	Active
DSH500150G	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Battle Ground	1910 SW 9th Avenue, Suite 100	Battle Ground	WA	Terminated
DSH500150H	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Family Medicine / LMG Salmon Creek Family Med 625-3963	2101 NE 139th St	Vancouver	WA	Active
DSH500150J	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Magnetic Resonance Imaging / MRI 600-3523	2101 NE 139th St	Vancouver	WA	Active
DSH500150K	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Pain Management Center / Pain Mgmt Center 600-3045	2101 NE 139th St	Vancouver	WA	Active
DSH500150L	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Breast Health Center / Mammography Center 600-3520	2101 NE 139th St	Vancouver	WA	Active
DSH500150M	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Nuclear Medicine / Nuclear Medicine 600-3522	2101 NE 139th St	Vancouver	WA	Active
DSH500150N	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Ultrasound / Ultrasound 600-3518	2101 NE 139th St	Vancouver	WA	Active
DSH500150P	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Day Treatment Unit / Day Treatment Clinics 600-3552	2121 NE 139th St	Vancouver	WA	Active
DSH500150Q	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Cardiac Rehabilitation / Cardiac Rehab 600-3440	2121 NE 139th St	Vancouver	WA	Active
DSH500150R	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Salmon Creek / LMG Salmon Creek IM 625-3961	2101 NE 139th Street	Vancouver	WA	Active
DSH500150S	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Wound Ostomy Clinic / Enterostomal Svcs 600-2170	2121 NE 139th St	Vancouver	WA	Active
DSH500150T	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek DTU at the Vancouver Clinic / TVC Infusion Clinic 600-3550	700 NE 87th Ave	Vancouver	WA	Active
DSH500150U	Child	DSH	LEGACY SALMON CREEK HOSPITAL	LEGACY MEDICAL GROUP GYNECOLOGIC ONCOLOGY-SALMON CREEK MEDICAL CENTER - GYNECOLOGIC ONCOLOGY	2121 NE 139th St	Vancouver	WA	Terminated
DSH500150V	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Oncology at the Vancouver Clinic / TVC Infusion Clinic 600-3550	700 NE 87th Ave	Vancouver	WA	Active
DSH500150W	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Salmon Creek Diabetes Services / LMG Salmon Creek IM 625-3961	2101 NE 139th St	Vancouver	WA	Active
DSH500150X	Child	DSH	LEGACY SALMON CREEK HOSPITAL	Legacy Medical Group Geriatrics Salmon Creek / LMG Salmon Creek IM 625-3961	2101 NE 139th St	Vancouver	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Tanas, Majid VP Pharmacy Services Legacy Health 5034155011	Kelly, Kecia SVP Chief Nursing Officer Legacy Health 5034155199	9/16/2024 7:42 AM
Details	Last Recertification Date	Update	Recertification	9/7/2023 5:47:22 PM	9/2/2024 10:34:53 AM	9/2/2024 10:34 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 7:08:46 PM	9/7/2023 5:47:22 PM	9/7/2023 5:47 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 7:05:11 PM	9/8/2022 7:08:46 PM	9/8/2022 7:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		027978	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OR	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1016776	6/13/2022 6:49 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WA	6/13/2022 6:49 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700809829	6/13/2022 6:49 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OR	6/13/2022 6:49 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700809829	6/13/2022 6:49 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WA	6/13/2022 6:49 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 10:12:11 AM	9/9/2021 7:05:11 PM	9/9/2021 7:05 PM
Contacts	Authorizing Official	Update	Change Request	Loomis, Anna SVP Chief Financial Officer Legacy Health 5034155730	Tanas, Majid VP Pharmacy Services Legacy Health 5034155011	1/25/2021 10:45 AM
Addresses	Main Address	Update	Recertification	700 NE 87th Ave, Suite 360 Vancouver, WA 98664	700 NE 87th Ave 360 Vancouver, WA 98664	9/8/2020 10:12 AM
Details	Last Recertification Date	Update	Recertification	9/6/2019 8:52:50 PM	9/8/2020 10:12:11 AM	9/8/2020 10:12 AM
Details	Entity Subname	Update	Recertification	LEGACY SALMON CREEK ONCOLOGY AT THE VANCOUVER CLINC - Oncology	Legacy Salmon Creek Oncology at the Vancouver Clinic / TVC Infusion Clinic 600-3550	9/8/2020 10:12 AM
Contacts	Primary Contact	Update	Profile Change Request	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034137764	Valcarlos, Elena Pharmacy Systems Manager Legacy Health 5034137764	1/31/2020 4:08 PM
Contacts	Primary Contact	Update	Profile Change Request	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034131321	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034137764	1/31/2020 4:08 PM
Contacts	Authorizing Official	Update	Change Request	Bradley, Carol SVP and Chief Nursing Officer Legacy Health 5034155199	Loomis, Anna SVP Chief Financial Officer Legacy Health 5034155730	9/15/2019 1:43 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 7:53:39 AM	9/6/2019 8:52:50 PM	9/6/2019 8:52 PM
Contacts	Primary Contact	Update	Change Request	Stoner, Kathleen C. Vice President Supply Chain and Pharmacy Services Legacy Health 5039444276	Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034131321	8/13/2019 7:11 AM
Contacts	Authorizing Official	Update	AO Change Request	Newcomb III, Everett W. Sr Vice President and COO Legacy Health 5034155252	Bradley, Carol SVP and Chief Nursing Officer Legacy Health 5034155199	12/31/2018 7:19 AM
Contacts	Primary Contact	Update	Profile Change Request	Stoner, Kathleen C. Director, LH Pharmacy Services Legacy Health 5034136926	Stoner, Kathleen C. Vice President Supply Chain and Pharmacy Services Legacy Health 5039444276	9/7/2018 1:25 PM
Addresses	Main Address	Update	Recertification	700 NE 87th Ave Vancouver, WA 98664	700 NE 87th Ave, Suite 360 Vancouver, WA 98664	8/24/2018 7:53 AM
Details	Last Recertification Date	Update	Recertification		8/24/2018 7:53:39 AM	8/24/2018 7:53 AM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Newcomb III, Everett W. Sr Vice President and COO Legacy Health 5034155252	11/21/2017 8:48 AM
Details	340B ID	Update	New Registration		DSH500150V	11/21/2017 8:48 AM
Details	Entity Subname	Update	New Registration	LEGACY SALMON CREEK ONCOLOGY AT THE VANCOUVER CLINC	LEGACY SALMON CREEK ONCOLOGY AT THE VANCOUVER CLINC - Oncology	11/21/2017 8:48 AM
Dates	Participating Approval Date	Update	New Registration		11/21/2017 8:48:15 AM	11/21/2017 8:48 AM
Details	State	Update	New Registration	Pending	Approved	11/21/2017 8:48 AM
Dates	Signed By Date	Update	New Registration		10/12/2017 12:05:02 PM	11/21/2017 8:48 AM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	11/21/2017 8:48 AM
Addresses	Main Address	Insert	New Registration		700 NE 87th Ave Vancouver, WA 98664	10/11/2017 7:38 PM
Contacts	Primary Contact	Insert	New Registration		Stoner, Kathleen C. Director, LH Pharmacy Services Legacy Health 5034136926	10/11/2017 7:38 PM
Contacts	Authorizing Official	Insert	New Registration		Newcomb III, Everett W. Sr Vice President and COO Legacy Health 5034155252	10/11/2017 7:38 PM
Details	Last Recertification Date	Insert	New Registration			10/11/2017 7:38 PM
Details	Grant Number	Insert	New Registration			10/11/2017 7:38 PM
Details	340B ID	Insert	New Registration			10/11/2017 7:38 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2017 7:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2017 7:38 PM
Details	Medicare Provider Number	Insert	New Registration		500150	10/11/2017 7:38 PM
Details	Entity Name	Insert	New Registration		LEGACY SALMON CREEK HOSPITAL	10/11/2017 7:38 PM
Details	Program Code	Insert	New Registration		DSH	10/11/2017 7:38 PM
Details	Entity Subname	Insert	New Registration		LEGACY SALMON CREEK ONCOLOGY AT THE VANCOUVER CLINC	10/11/2017 7:38 PM
Dates	Participating Approval Date	Insert	New Registration			10/11/2017 7:38 PM
Details	State	Insert	New Registration		Pending	10/11/2017 7:38 PM
Dates	Registration Date	Insert	New Registration		10/11/2017 7:38:17 PM	10/11/2017 7:38 PM
Dates	Signed By Date	Insert	New Registration			10/11/2017 7:38 PM
Dates	Start Date	Insert	New Registration			10/11/2017 7:38 PM
Terminations	Termination Comments	Insert	New Registration			10/11/2017 7:38 PM
Terminations	Termination Date	Insert	New Registration			10/11/2017 7:38 PM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2017 7:38 PM
Terminations	Termination Reason	Insert	New Registration			10/11/2017 7:38 PM