Covered Entity Details

RRC500039-02 ST. MICHAEL MEDICAL CENTER (Terminated) - information as of 5/12/2025 10:15:26 PM

Main Details

Name

ST. MICHAEL MEDICAL CENTER

Subdivision Name

St. Michael Medical Center - Cancer Center Infusion Clinic

Type

Rural Referral Center

Rural

340B ID

RRC500039-02

Medicare Provider Number

500039

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/12/2017

Participating Start Date

1/1/2018

Participating Approval Date

10/27/2017

Last Recertification Date

8/28/2020

Termination Date
Termination Reason

7/1/2021
Business decision by the Covered Entity

Contacts

Authorizing Official

CHI Franciscan Health
David Butcherite, CFO
(253) 680-4031

Primary Contact

St. Michael Medical Center (formerly Harrison Medical Center)
Charles C Ho, Director of Pharmacy
(714) 658-2517

Addresses

Street Address

1900 NW Myhre Road
Silverdale, WA 98383

Billing Address

St Michael Medical Center
1800 NW Myhre Road
Silverdale, WA 98383

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		1518912609

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
RRC500039-01	Child	RRC	ST. MICHAEL MEDICAL CENTER	St. Michael Medical Center - Cancer Center Infusion Clinic	1900 NW Myhre Road	Silverdale	WA	Active
RRC500039-02	Child	RRC	ST. MICHAEL MEDICAL CENTER	St. Michael Medical Center - Cancer Center Infusion Clinic	1900 NW Myhre Road	Silverdale	WA	Terminated
RRC500039-03	Child	RRC	ST. MICHAEL MEDICAL CENTER	ST. MICHAEL MEDICAL CENTER - Infusion Center (Optimum)	742 LEBO BLVD STE A	BREMERTON	WA	Active
RRC500039-04	Child	RRC	ST. MICHAEL MEDICAL CENTER	ST. MICHAEL MEDICAL CENTER - Bremerton Emergency Room	2520 Cherry Avenue	BREMERTON	WA	Terminated
RRC500039-05	Child	RRC	ST. MICHAEL MEDICAL CENTER	Silverdale Campus Surgery Ortho	1800 NW MYHRE ROAD	SILVERDALE	WA	Terminated
RRC500039-06	Child	RRC	ST. MICHAEL MEDICAL CENTER	ST. MICHAEL MEDICAL CENTER - Silverdale Campus Surgery	1800 NW MYHRE ROAD	SILVERDALE	WA	Terminated
RRC500039-07	Child	RRC	ST. MICHAEL MEDICAL CENTER	ST. MICHAEL MEDICAL CENTER - Silverdale Campus PACU	1800 NW MYHRE ROAD	SILVERDALE	WA	Terminated
RRC500039-08	Child	RRC	ST. MICHAEL MEDICAL CENTER	St. Michael Medical Center Silverdale Campus PACU Ortho	1800 NW MYHRE ROAD	SILVERDALE	WA	Terminated
RRC500039-09	Child	RRC	ST. MICHAEL MEDICAL CENTER	ST. MICHAEL MEDICAL CENTER - Silverdale Campus Obstetrical Emergency	1800 NW MYHRE ROAD	SILVERDALE	WA	Terminated
RRC500039-10	Child	RRC	ST. MICHAEL MEDICAL CENTER	ST. MICHAEL MEDICAL CENTER - Silverdale Campus Orthopedic Unit	1800 NW MYHRE ROAD	SILVERDALE	WA	Terminated
RRC500039-11	Child	RRC	ST. MICHAEL MEDICAL CENTER	ST. Michael Medical Center Silverdale Campus Family Birth Center (LDRP & Nursery)	1800 NW MYHRE ROAD	SILVERDALE	WA	Terminated
RRC500039-12	Child	RRC	ST. MICHAEL MEDICAL CENTER	St. Michael Medical Center Belfair Urgent Care	21 NE ROMANCE HILL ROAD	BELFAIR	WA	Active
RRC500039-13	Child	RRC	HARRISON MEDICAL CENTER	HARRISON MEDICAL CENTER - Harrison Bainbridge Urgent Care	8804 MADISON AVE NE STE 100	BAINBRIDGE ISLAND	WA	Terminated
RRC500039-14	Child	RRC	ST. MICHAEL MEDICAL CENTER	ST. MICHAEL MEDICAL CENTER - Port Orchard Urgent Care	450 S KITSAP BLVD STE 100	PORT ORCHARD	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/28/2021 12:00:00 AM	5/24/2021 11:21 AM
Details	State	Update	Termination Request	Active	To Be Terminated	5/24/2021 11:21 AM
Terminations	Termination Comments	Update	Termination Request		After moving to new location (and combined into one address) we don't need separate registration. Never became ineligible (as there's a ineligible date required above, mandatory). Will put down the date of next quarter review (7/1/21). Thank you.	5/24/2021 11:21 AM
Terminations	Termination Date	Update	Termination Request		7/1/2021 12:00:00 AM	5/24/2021 11:21 AM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2021 12:00:00 AM	5/24/2021 11:21 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	5/24/2021 11:21 AM
Addresses	Main Address	Update	Change Request	2720 Clare Avenue STE A Bremerton, WA 98310-3374	1900 NW Myhre Road Silverdale, WA 98383	5/12/2021 8:01 AM
Addresses	Billing Address	Update	Change Request	St Michael Medical Center 2520 Cherry Avenue Bremerton, WA 98310	St Michael Medical Center 1800 NW Myhre Road Silverdale, WA 98383	5/12/2021 8:01 AM
Details	Entity Subname	Update	Change Request	St. Michael Medical Center Infusion Clinic Bremerton (Med Oncology Bremerton)	St. Michael Medical Center - Cancer Center Infusion Clinic	5/12/2021 8:01 AM
Addresses	Billing Address	Update	Change Request	Harrison Medical Center 2520 Cherry Avenue Bremerton, WA 98310	St Michael Medical Center 2520 Cherry Avenue Bremerton, WA 98310	4/23/2021 6:53 AM
Details	Entity Subname	Update	Change Request	Harrison Medical Center - Harrison Infusion Clinic Bremerton (Med Oncology Bremerton)	St. Michael Medical Center Infusion Clinic Bremerton (Med Oncology Bremerton)	4/23/2021 6:53 AM
Contacts	Primary Contact	Update	Profile Change Request	Ho, Charles C Director of Pharmacy Harrison Medical Center 3607446566	Ho, Charles C Director of Pharmacy St. Michael Medical Center (formerly Harrison Medical Center) 7146582517	4/15/2021 6:17 PM
Contacts	Authorizing Official	Update	Change Request	Fitzgerald, Mike CFO CHI Franciscan Health 2536804005	Butcherite, David CFO CHI Franciscan Health 2536804031	4/14/2021 2:53 PM
Details	Entity Name	Update	Recertification	HARRISON MEDICAL CENTER	ST. MICHAEL MEDICAL CENTER	9/16/2020 8:05 AM
Medicaid Billing	NPI: State	Update	Recertification		WA	8/28/2020 4:24 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 2:17:24 PM	8/28/2020 4:24:49 PM	8/28/2020 4:24 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 5:10:22 PM	8/27/2019 2:17:24 PM	8/27/2019 2:17 PM
Contacts	Primary Contact	Update	Change Request	Wilson, Cindy 340B Program Manager CHI Franciscan Health 2534266692	Ho, Charles C Director of Pharmacy Harrison Medical Center 3607446566	5/31/2019 8:07 AM
Addresses	Billing Address	Update	Change Request	Harrison Medical Center PO Box 63600 Littleton, CO 80163-6000	Harrison Medical Center 2520 Cherry Avenue Bremerton, WA 98310	5/22/2019 6:06 PM
Details	Last Recertification Date	Update	Recertification		8/16/2018 5:10:22 PM	8/16/2018 5:10 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Fitzgerald, Mike CFO CHI Franciscan Health 2536804005	10/27/2017 11:48 AM
Details	340B ID	Update	New Registration		RRC500039-02	10/27/2017 11:48 AM
Details	Entity Subname	Update	New Registration	Harrison Medical Center	Harrison Medical Center - Harrison Infusion Clinic Bremerton (Med Oncology Bremerton)	10/27/2017 11:48 AM
Dates	Participating Approval Date	Update	New Registration		10/27/2017 11:48:37 AM	10/27/2017 11:48 AM
Details	State	Update	New Registration	Pending	Approved	10/27/2017 11:48 AM
Dates	Signed By Date	Update	New Registration		10/13/2017 4:45:44 PM	10/27/2017 11:48 AM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	10/27/2017 11:48 AM
Addresses	Main Address	Insert	New Registration		2720 Clare Avenue STE A Bremerton, WA 98310-3374	10/12/2017 1:23 PM
Addresses	Billing Address	Insert	New Registration		Harrison Medical Center PO Box 63600 Littleton, CO 80163-6000	10/12/2017 1:23 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1518912609	10/12/2017 1:23 PM
Contacts	Authorizing Official	Insert	New Registration		Fitzgerald, Mike CFO CHI Franciscan Health 2536804005	10/12/2017 1:23 PM
Contacts	Primary Contact	Insert	New Registration		Wilson, Cindy 340B Program Manager CHI Franciscan Health 2534266692	10/12/2017 1:23 PM
Details	Last Recertification Date	Insert	New Registration			10/12/2017 1:23 PM
Details	Grant Number	Insert	New Registration			10/12/2017 1:23 PM
Details	340B ID	Insert	New Registration			10/12/2017 1:23 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/12/2017 1:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/12/2017 1:23 PM
Details	Medicare Provider Number	Insert	New Registration		500039	10/12/2017 1:23 PM
Details	Entity Name	Insert	New Registration		HARRISON MEDICAL CENTER	10/12/2017 1:23 PM
Details	Program Code	Insert	New Registration		RRC	10/12/2017 1:23 PM
Details	Entity Subname	Insert	New Registration		Harrison Medical Center	10/12/2017 1:23 PM
Dates	Participating Approval Date	Insert	New Registration			10/12/2017 1:23 PM
Details	State	Insert	New Registration		Pending	10/12/2017 1:23 PM
Dates	Registration Date	Insert	New Registration		10/12/2017 1:23:22 PM	10/12/2017 1:23 PM
Dates	Signed By Date	Insert	New Registration			10/12/2017 1:23 PM
Dates	Start Date	Insert	New Registration			10/12/2017 1:23 PM
Terminations	Termination Comments	Insert	New Registration			10/12/2017 1:23 PM
Terminations	Termination Date	Insert	New Registration			10/12/2017 1:23 PM
Terminations	Termination Effective Date	Insert	New Registration			10/12/2017 1:23 PM
Terminations	Termination Reason	Insert	New Registration			10/12/2017 1:23 PM