Covered Entity Details

DSH050394H CMH OF SAN BUENAVENTURA (Active) - information as of 5/23/2025 12:20:17 AM

Main Details

Name

CMH OF SAN BUENAVENTURA

Subdivision Name

CMH Centers for Family Health-Saviers - Primary Care

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050394H

Medicare Provider Number

050394

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/4/2019

Participating Start Date

1/1/2020

Participating Approval Date

11/24/2019

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Community Memorial Health System
James A Corwin, Chief Financial Officer
(805) 948-5003

Primary Contact

Community Memorial Health System
Jacek Tretko, Director of Pharmacy Services
(805) 652-5068

Addresses

Street Address

2921 Saviers Road
Oxnard, CA 93033-5314

Billing Address

Community Memorial Health System
147 N Brent St
Ventura, CA 93003

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
CA		1740228345,1215903018

Shipping Addresses

Shipping Address 1

Community Memorial Hospital Ventura
147 N Brent St
Ventura, CA 93003

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
DSH050394A	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Main Street - Primary Care	138 W Main Street	Ventura	CA	Active
DSH050394B	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Vineyard - Primary Care	2361 E Vineyard Avenue	Oxnard	CA	Active
DSH050394C	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Midtown Medical Group - Primary Care	2721 E Main Street	Ventura	CA	Active
DSH050394D	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Fillmore - Primary Care	852 W Ventura Road	Fillmore	CA	Active
DSH050394E	Child	DSH	CMH OF SAN BUENAVENTURA	Santa Rosa Health Clinic - Primary Care	5800 Santa Rosa Road	Camarillo	CA	Active
DSH050394F	Child	DSH	CMH OF SAN BUENAVENTURA	San Buenaventura Urology Center - Urology	2705 Loma Vista Road	Ventura	CA	Active
DSH050394G	Child	DSH	CMH OF SAN BUENAVENTURA	Premier Health Center - Primary Care	258 E Harvard Blvd	Santa Paula	CA	Active
DSH050394H	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Saviers - Primary Care	2921 Saviers Road	Oxnard	CA	Active
DSH050394J	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Ashwood - Primary Care	120 N Ashwood Drive	Ventura	CA	Active
DSH050394K	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Santa Paula - Primary Care	242 E Harvard Blvd	Santa Paula	CA	Active
DSH050394L	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Camarillo - Primary Care	422 Arneill Road	Camarillo	CA	Active
DSH050394M	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Same Day Surgery - Outpatient Surgery	168 N Brent Street	Ventura	CA	Active
DSH050394N	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Midtown Medical Group - Specialty Clinic	168 N Brent Street	Ventura	CA	Active
DSH050394P	Child	DSH	CMH OF SAN BUENAVENTURA	Center for Wound Care - Wound Care	2705 Loma Vista Road	Ventura	CA	Active
DSH050394Q	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Airport - Primary Care	3641 W 5th Street	Oxnard	CA	Active
DSH050394R	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Centers for Family Health-Port Hueneme - Primary Care	321 E Port Hueneme Road	Port Hueneme	CA	Active
DSH050394S	Child	DSH	CMH OF SAN BUENAVENTURA	Central Coast Center for Gynecological Oncology - Gynecology/Oncology	2900 Loma Vista Road	Ventura	CA	Active
DSH050394T	Child	DSH	CMH OF SAN BUENAVENTURA	CMH Midtown Medical Group - Pediatrics - Pediatric	3655 W 5th Street	Oxnard	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Group Change Request		1215903018	11/27/2024 3:43 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		CA	11/27/2024 3:43 PM
Contacts	Primary Contact	Update	Profile Change Request	Tretko, Jacek Director of Outpatient Pharmacy and Purchasing Community Memorial Health System 8056525068	Tretko, Jacek Director of Pharmacy Services Community Memorial Health System 8056525068	11/26/2024 12:41 PM
Details	Last Recertification Date	Update	Recertification	8/18/2023 3:45:15 PM	8/12/2024 8:14:39 PM	8/12/2024 8:14 PM
Details	Last Recertification Date	Update	Recertification	8/24/2022 6:05:55 PM	8/18/2023 3:45:15 PM	8/18/2023 3:45 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 5:22:44 PM	8/24/2022 6:05:55 PM	8/24/2022 6:05 PM
Addresses	Billing Address	Update	Change Request	Community Memorial Health System 5855 Olivas Park Drive Ventura, CA 93003	Community Memorial Health System 147 N Brent St Ventura, CA 93003	6/22/2022 8:35 AM
Addresses	Shipping Address	Insert	Change Request		Community Memorial Hospital Ventura 147 N Brent St Ventura, CA 93003	6/22/2022 8:35 AM
Contacts	Primary Contact	Update	Group Change Request	Day, Eugene Luke Director of Pharmacy Services Community Memorial Health System 8056525069	Tretko, Jacek Director of Outpatient Pharmacy and Purchasing Community Memorial Health System 8056525068	11/16/2021 2:55 PM
Details	Last Recertification Date	Update	Recertification	9/1/2020 11:21:27 AM	8/17/2021 5:22:44 PM	8/17/2021 5:22 PM
Contacts	Authorizing Official	Update	AO Change Request	GLYER, DAVID BURRIS cfo Community Memorial Health System 8056525003	Corwin, James A Chief Financial Officer Community Memorial Health System 8059485003	12/7/2020 8:05 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/1/2020 11:21 AM
Details	Last Recertification Date	Update	Recertification		9/1/2020 11:21:27 AM	9/1/2020 11:21 AM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		GLYER, DAVID BURRIS cfo Community Memorial Health System 8056525003	11/24/2019 6:14 PM
Details	340B ID	Update	New Registration		DSH050394H	11/24/2019 6:14 PM
Details	Entity Subname	Update	New Registration	CMH Centers for Family Health-Saviers	CMH Centers for Family Health-Saviers - Primary Care	11/24/2019 6:14 PM
Dates	Participating Approval Date	Update	New Registration		11/24/2019 6:14:28 PM	11/24/2019 6:14 PM
Details	State	Update	New Registration	Pending	Approved	11/24/2019 6:14 PM
Dates	Signed By Date	Update	New Registration		10/4/2019 7:30:18 PM	11/24/2019 6:14 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	11/24/2019 6:14 PM
Addresses	Main Address	Insert	New Registration		2921 Saviers Road Oxnard, CA 93033-5314	10/4/2019 7:30 PM
Addresses	Billing Address	Insert	New Registration		Community Memorial Health System 5855 Olivas Park Drive Ventura, CA 93003	10/4/2019 7:30 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1740228345	10/4/2019 7:30 PM
Contacts	Primary Contact	Insert	New Registration		Day, Eugene Luke Director of Pharmacy Services Community Memorial Health System 8056525069	10/4/2019 7:30 PM
Contacts	Authorizing Official	Insert	New Registration		GLYER, DAVID BURRIS cfo Community Memorial Health System 8056525003	10/4/2019 7:30 PM
Details	Last Recertification Date	Insert	New Registration			10/4/2019 7:30 PM
Details	Grant Number	Insert	New Registration			10/4/2019 7:30 PM
Details	340B ID	Insert	New Registration			10/4/2019 7:30 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/4/2019 7:30 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/4/2019 7:30 PM
Details	Medicare Provider Number	Insert	New Registration		050394	10/4/2019 7:30 PM
Details	Entity Name	Insert	New Registration		CMH OF SAN BUENAVENTURA	10/4/2019 7:30 PM
Details	Program Code	Insert	New Registration		DSH	10/4/2019 7:30 PM
Details	Entity Subname	Insert	New Registration		CMH Centers for Family Health-Saviers	10/4/2019 7:30 PM
Dates	Participating Approval Date	Insert	New Registration			10/4/2019 7:30 PM
Details	State	Insert	New Registration		Pending	10/4/2019 7:30 PM
Dates	Registration Date	Insert	New Registration		10/4/2019 7:30:16 PM	10/4/2019 7:30 PM
Dates	Signed By Date	Insert	New Registration			10/4/2019 7:30 PM
Dates	Start Date	Insert	New Registration			10/4/2019 7:30 PM
Terminations	Termination Comments	Insert	New Registration			10/4/2019 7:30 PM
Terminations	Termination Date	Insert	New Registration			10/4/2019 7:30 PM
Terminations	Termination Effective Date	Insert	New Registration			10/4/2019 7:30 PM
Terminations	Termination Reason	Insert	New Registration			10/4/2019 7:30 PM