Covered Entity Details

RRC500039-10 ST. MICHAEL MEDICAL CENTER (Terminated) - information as of 4/25/2025 6:33:40 PM

Main Details

Name

ST. MICHAEL MEDICAL CENTER

Subdivision Name

ST. MICHAEL MEDICAL CENTER - Silverdale Campus Orthopedic Unit

Type

Rural Referral Center

Rural

340B ID

RRC500039-10

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

11/6/2017

Last Recertification Date

9/14/2020

Termination Date
Termination Reason

7/1/2021
Outpatient facility moved within the 4 walls of the parent hospital

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

1800 NW MYHRE ROAD
SILVERDALE, WA 98383-7663

Billing Address

Harrison Medical Center
2520 Cherry Avenue
Bremerton, WA 98310

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

Shipping Address 1

Harrison Medical Center
1780 NW Myhre Road
Silverdale, WA 98383

Shipping Address 2

Harrison Medical Center
2520 Cherry Avenue
Bremerton, WA 98310

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		7/1/2021 12:00:00 AM	5/24/2021 11:22 AM
Details	State	Update	Termination Request	Active	To Be Terminated	5/24/2021 11:22 AM
Terminations	Termination Comments	Update	Termination Request		Moved to within 4 walls of hospital. No longer needs to be separately registered.	5/24/2021 11:22 AM
Terminations	Termination Date	Update	Termination Request		7/1/2021 12:00:00 AM	5/24/2021 11:22 AM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2021 12:00:00 AM	5/24/2021 11:22 AM
Terminations	Termination Reason	Update	Termination Request		Outpatient facility moved within the 4 walls of the parent hospital	5/24/2021 11:22 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	9/14/2020 9:10 AM
Details	Last Recertification Date	Update	Recertification	8/27/2019 2:17:04 PM	9/14/2020 9:10:25 AM	9/14/2020 9:10 AM
Details	Entity Subname	Update	Recertification	HARRISON MEDICAL CENTER - Silverdale Campus Orthopedic Unit	ST. MICHAEL MEDICAL CENTER - Silverdale Campus Orthopedic Unit	9/14/2020 9:10 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 6:23:22 AM	8/27/2019 2:17:04 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 8:10 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 6:13 PM
Addresses	Shipping Address	Insert	Recertification		Harrison Medical Center 2520 Cherry Avenue Bremerton, WA 98310	8/23/2018 6:23 AM
Details	Last Recertification Date	Update	Recertification		8/23/2018 6:23:22 AM	8/23/2018 6:23 AM
Addresses	Shipping Address	Insert	Change Request		Harrison Medical Center 1780 NW Myhre Road Silverdale, WA 98383	1/16/2018 9:48 AM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Fitzgerald, Mike CFO CHI Franciscan Health 2536804005	11/6/2017 8:00 AM
Details	340B ID	Update	New Registration		RRC500039-10	11/6/2017 8:00 AM
Details	Entity Subname	Update	New Registration	HARRISON MEDICAL CENTER	HARRISON MEDICAL CENTER - Silverdale Campus Orthopedic Unit	11/6/2017 8:00 AM
Dates	Participating Approval Date	Update	New Registration		11/6/2017 8:01:00 AM	11/6/2017 8:00 AM
Details	State	Update	New Registration	Pending	Approved	11/6/2017 8:00 AM
Dates	Signed By Date	Update	New Registration		11/3/2017 4:22:17 PM	11/6/2017 8:00 AM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	11/6/2017 8:00 AM
Addresses	Main Address	Insert	New Registration		1800 NW MYHRE ROAD SILVERDALE, WA 98383-7663	10/12/2017 2:10 PM
Addresses	Billing Address	Insert	New Registration		Harrison Medical Center PO Box 63600 Littleton, CO 80163-6000	10/12/2017 2:10 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1518912609	10/12/2017 2:10 PM
Contacts	Authorizing Official	Insert	New Registration		Fitzgerald, Mike CFO CHI Franciscan Health 2536804005	10/12/2017 2:10 PM
Contacts	Primary Contact	Insert	New Registration		Wilson, Cindy 340B Program Manager CHI Franciscan Health 2534266692	10/12/2017 2:10 PM
Details	Last Recertification Date	Insert	New Registration			10/12/2017 2:10 PM
Details	Grant Number	Insert	New Registration			10/12/2017 2:10 PM
Details	340B ID	Insert	New Registration			10/12/2017 2:10 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/12/2017 2:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/12/2017 2:10 PM
Details	Medicare Provider Number	Insert	New Registration		500039	10/12/2017 2:10 PM
Details	Entity Name	Insert	New Registration		HARRISON MEDICAL CENTER	10/12/2017 2:10 PM
Details	Program Code	Insert	New Registration		RRC	10/12/2017 2:10 PM
Details	Entity Subname	Insert	New Registration		HARRISON MEDICAL CENTER	10/12/2017 2:10 PM
Dates	Participating Approval Date	Insert	New Registration			10/12/2017 2:10 PM
Details	State	Insert	New Registration		Pending	10/12/2017 2:10 PM
Dates	Registration Date	Insert	New Registration		10/12/2017 2:10:12 PM	10/12/2017 2:10 PM
Dates	Signed By Date	Insert	New Registration			10/12/2017 2:10 PM
Dates	Start Date	Insert	New Registration			10/12/2017 2:10 PM
Terminations	Termination Comments	Insert	New Registration			10/12/2017 2:10 PM
Terminations	Termination Date	Insert	New Registration			10/12/2017 2:10 PM
Terminations	Termination Effective Date	Insert	New Registration			10/12/2017 2:10 PM
Terminations	Termination Reason	Insert	New Registration			10/12/2017 2:10 PM