Covered Entity Details

CAH501333-08 KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1 (Active) - information as of 5/20/2025 12:53:42 AM

Main Details

Name

KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1

Subdivision Name

KVH Workplace Health - Workplace Health

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH501333-08

Medicare Provider Number

501333

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/3/2019

Participating Start Date

10/1/2019

Participating Approval Date

7/10/2019

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Kittitas Valley Healthcare
Rhonda Holden, Chief Ancillary Officer
(509) 962-7320

Primary Contact

Kittitas Valley Healthcare Hospital
Nasser Basmeh, Director of Pharmacy
(509) 962-7420

Addresses

Street Address

702 E. Mountain View Ave
2
Ellensburg, WA 98926

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?
No

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
CAH501333-01	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	Kittitas Vally Healthcare - Family Medicine - Cle Elum	201 Alpha Way	Cle Elum	WA	Active
CAH501333-02	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	Kittitas Valley Healthcare - Adult & Internal Medicine	700 E. Manitoba Ave. Ste 101	Ellensburg	WA	Active
CAH501333-03	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	Kittitas Valley Healthcare - Orthopedics	100 E Jackson Suite 201 Medical Arts Center	Ellensburg	WA	Active
CAH501333-04	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	Kittitas Valley Healthcare - General Surgery	611 S. Chestnut St. Suite A	Ellensburg	WA	Active
CAH501333-05	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	Kittitas Valley Clinic - Family Medicine - Ellensburg Medical Arts Center Clinic	100 E. Jackson Ave.	Ellensburg	WA	Active
CAH501333-06	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	Kittitas Valley Healthcare - Women's Health- Medical Arts Center	100 E Jackson Ave	Ellensburg	WA	Active
CAH501333-07	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	KVH Urgent Care - Urgent Care Clinic	214 W 1st St	Cle Elum	WA	Active
CAH501333-08	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	KVH Workplace Health - Workplace Health	702 E. Mountain View Ave	Ellensburg	WA	Active
CAH501333-09	Child	CAH	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	KVH Pediatrics - Pediatrics Medical Arts Center	100 E. Jackson Ave.	Ellensburg	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/18/2023 5:36:23 PM	8/12/2024 1:15:21 PM	8/12/2024 1:15 PM
Details	Last Recertification Date	Update	Recertification	8/25/2022 5:39:48 PM	8/18/2023 5:36:23 PM	8/18/2023 5:36 PM
Details	Last Recertification Date	Update	Recertification	8/18/2021 2:47:50 PM	8/25/2022 5:39:48 PM	8/25/2022 5:39 PM
Details	Last Recertification Date	Update	Recertification	8/17/2020 1:53:30 PM	8/18/2021 2:47:50 PM	8/18/2021 2:47 PM
Details	Last Recertification Date	Update	Recertification		8/17/2020 1:53:30 PM	8/17/2020 1:53 PM
Contacts	Authorizing Official	Update	Profile Change Request	Holden, Rhonda CNO Kittitas Valley Healthcare 5099627320	Holden, Rhonda Chief Ancillary Officer Kittitas Valley Healthcare 5099627320	8/10/2020 2:32 PM
Contacts	Signed By	Update	Profile Change Request	Holden, Rhonda CNO Kittitas Valley Healthcare 5099627320	Holden, Rhonda Chief Ancillary Officer Kittitas Valley Healthcare 5099627320	8/10/2020 2:32 PM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		Holden, Rhonda CNO Kittitas Valley Healthcare 5099627320	7/10/2019 6:03 AM
Details	340B ID	Update	New Registration		CAH501333-08	7/10/2019 6:03 AM
Details	Entity Name	Update	New Registration	KITTITAS VALLEY COMMUNITY HOSPITAL	KITTITAS COUNTY PUBLIC HOSPITAL DISTRICT #1	7/10/2019 6:03 AM
Details	Entity Subname	Update	New Registration	KVH Workplace Health	KVH Workplace Health - Workplace Health	7/10/2019 6:03 AM
Dates	Participating Approval Date	Update	New Registration		7/10/2019 6:03:35 AM	7/10/2019 6:03 AM
Details	State	Update	New Registration	Pending	Approved	7/10/2019 6:03 AM
Dates	Signed By Date	Update	New Registration		7/8/2019 12:33:12 PM	7/10/2019 6:03 AM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	7/10/2019 6:03 AM
Addresses	Main Address	Insert	New Registration		702 E. Mountain View Ave 2 Ellensburg, WA 98926	7/3/2019 5:29 PM
Contacts	Primary Contact	Insert	New Registration		Basmeh, Nasser Director of Pharmacy Kittitas Valley Healthcare Hospital 5099627420	7/3/2019 5:29 PM
Contacts	Authorizing Official	Insert	New Registration		Holden, Rhonda CNO Kittitas Valley Healthcare 5099627320	7/3/2019 5:29 PM
Details	Last Recertification Date	Insert	New Registration			7/3/2019 5:29 PM
Details	Grant Number	Insert	New Registration			7/3/2019 5:29 PM
Details	340B ID	Insert	New Registration			7/3/2019 5:29 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/3/2019 5:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/3/2019 5:29 PM
Details	Medicare Provider Number	Insert	New Registration		501333	7/3/2019 5:29 PM
Details	Entity Name	Insert	New Registration		KITTITAS VALLEY COMMUNITY HOSPITAL	7/3/2019 5:29 PM
Details	Program Code	Insert	New Registration		CAH	7/3/2019 5:29 PM
Details	Entity Subname	Insert	New Registration		KVH Workplace Health	7/3/2019 5:29 PM
Dates	Participating Approval Date	Insert	New Registration			7/3/2019 5:29 PM
Details	State	Insert	New Registration		Pending	7/3/2019 5:29 PM
Dates	Registration Date	Insert	New Registration		7/3/2019 5:29:08 PM	7/3/2019 5:29 PM
Dates	Signed By Date	Insert	New Registration			7/3/2019 5:29 PM
Dates	Start Date	Insert	New Registration			7/3/2019 5:29 PM
Terminations	Termination Comments	Insert	New Registration			7/3/2019 5:29 PM
Terminations	Termination Date	Insert	New Registration			7/3/2019 5:29 PM
Terminations	Termination Effective Date	Insert	New Registration			7/3/2019 5:29 PM
Terminations	Termination Reason	Insert	New Registration			7/3/2019 5:29 PM