Covered Entity Details

DSH380025H LEGACY MOUNT HOOD MEDICAL CENTER (Active) - information as of 5/15/2025 1:59:27 AM

Main Details

Name

LEGACY MOUNT HOOD MEDICAL CENTER

Subdivision Name

Legacy Mount Hood Cardiac Rehabilitation / Cardiac Rehab 350-3440

Type

Disproportionate Share Hospital

Rural

340B ID

DSH380025H

Medicare Provider Number

380025

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/8/2020

Participating Start Date

4/1/2020

Participating Approval Date

2/5/2020

Last Recertification Date

9/3/2024

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

24988 SE Stark Street
320
Gresham, OR 97030

Billing Address

Legacy Mount Hood Medical Center
24800 SE Stark Street
Gresham, OR 97030

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	069526	1255354700

Shipping Addresses

Shipping Address 1

Legacy Mount Hood Medical Center
24800 SE Stark Street
Gresham, OR 97030

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
DSH380025A	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Medication Management Services / Anticoagulation Clinic 350-3719	24988 SE Stark St	Gresham	OR	Active
DSH380025B	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Ultrasound / Ultrasound 350-3518	24988 SE Stark Street	Gresham	OR	Active
DSH380025C	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Diabetes Services / Diabetes Svcs 350-3787	24988 SE Stark St	Gresham	OR	Active
DSH380025D	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Wound Ostomy Clinic / Enterostomal Svcs 350-2170	24988 SE Stark St	Gresham	OR	Active
DSH380025E	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Medical Group Mount Hood / LMG Mount Hood 355-8060	24988 SE Stark St	Gresham	OR	Active
DSH380025F	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Powell Butte Clinic	17332 SE Powell Blvd	Portland	OR	Terminated
DSH380025G	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Rehabilitation / Rehab 350-3612	24900 SE Stark St	Gresham	OR	Active
DSH380025H	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Cardiac Rehabilitation / Cardiac Rehab 350-3440	24988 SE Stark Street	Gresham	OR	Active
DSH380025J	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Radiation Oncology / Radiation Oncology 350-3542	24950 SE Stark Street	Gresham	OR	Active
DSH380025K	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Radiology / Radiology Diagnostic 350-3512	24988 SE Stark St	Gresham	OR	Active
DSH380025L	Child	DSH	LEGACY MOUNT HOOD MEDICAL CENTER	Legacy Mount Hood Breast and Outpatient Imaging Center / Mammography Center 350-3520	24988 SE Stark St	Gresham	OR	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	9/12/2024 11:20 AM
Addresses	Main Address	Update	Recertification	24988 SE Stark Street Medical Office Building 3 320 Gresham, OR 97030	24988 SE Stark Street 320 Gresham, OR 97030	9/3/2024 8:22 AM
Details	Last Recertification Date	Update	Recertification	9/8/2023 3:39:13 AM	9/3/2024 8:22:38 AM	9/3/2024 8:22 AM
Addresses	Main Address	Update	Recertification	24988 SE Stark Street 320 Gresham, OR 97030	24988 SE Stark Street Medical Office Building 3 320 Gresham, OR 97030	9/8/2023 3:39 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 1:09:50 PM	9/8/2023 3:39:13 AM	9/8/2023 3:39 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 7:03:28 PM	9/8/2022 1:09:50 PM	9/8/2022 1:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/13/2022 6:53 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		069526	6/13/2022 6:53 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OR	6/13/2022 6:53 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1255354700	6/13/2022 6:53 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		OR	6/13/2022 6:53 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 9:54:03 AM	9/9/2021 7:03:28 PM	9/9/2021 7:03 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 10:44 AM
Details	Last Recertification Date	Update	Recertification		9/8/2020 9:54:03 AM	9/8/2020 9:54 AM
Details	Entity Subname	Update	Recertification	Legacy Mt Hood Cardiac Rehabilitation - Cardiac Rehabilitation	Legacy Mount Hood Cardiac Rehabilitation / Cardiac Rehab 350-3440	9/8/2020 9:54 AM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Loomis, Anna SVP Chief Financial Officer Legacy Health 5034155730	2/5/2020 11:07 AM
Details	340B ID	Update	New Registration		DSH380025H	2/5/2020 11:07 AM
Details	Entity Subname	Update	New Registration	Legacy Mt Hood Cardiac Rehabilitation	Legacy Mt Hood Cardiac Rehabilitation - Cardiac Rehabilitation	2/5/2020 11:07 AM
Dates	Participating Approval Date	Update	New Registration		2/5/2020 11:07:24 AM	2/5/2020 11:07 AM
Details	State	Update	New Registration	Pending	Approved	2/5/2020 11:07 AM
Dates	Signed By Date	Update	New Registration		1/10/2020 3:03:07 PM	2/5/2020 11:07 AM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	2/5/2020 11:07 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
Addresses	Main Address	Insert	New Registration		24988 SE Stark Street 320 Gresham, OR 97030	1/8/2020 10:27 PM
Addresses	Billing Address	Insert	New Registration		Legacy Mount Hood Medical Center 24800 SE Stark Street Gresham, OR 97030	1/8/2020 10:27 PM
Addresses	Shipping Address	Insert	New Registration		Legacy Mount Hood Medical Center 24800 SE Stark Street Gresham, OR 97030	1/8/2020 10:27 PM
Contacts	Primary Contact	Insert	New Registration		Valcarlos, Elena Pharmacy Operations Manager Legacy Health 5034131321	1/8/2020 10:27 PM
Contacts	Authorizing Official	Insert	New Registration		Loomis, Anna SVP Chief Financial Officer Legacy Health 5034155730	1/8/2020 10:27 PM
Details	Last Recertification Date	Insert	New Registration			1/8/2020 10:27 PM
Details	Grant Number	Insert	New Registration			1/8/2020 10:27 PM
Details	340B ID	Insert	New Registration			1/8/2020 10:27 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/8/2020 10:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/8/2020 10:27 PM
Details	Medicare Provider Number	Insert	New Registration		380025	1/8/2020 10:27 PM
Details	Entity Name	Insert	New Registration		LEGACY MOUNT HOOD MEDICAL CENTER	1/8/2020 10:27 PM
Details	Program Code	Insert	New Registration		DSH	1/8/2020 10:27 PM
Details	Entity Subname	Insert	New Registration		Legacy Mt Hood Cardiac Rehabilitation	1/8/2020 10:27 PM
Dates	Participating Approval Date	Insert	New Registration			1/8/2020 10:27 PM
Details	State	Insert	New Registration		Pending	1/8/2020 10:27 PM
Dates	Registration Date	Insert	New Registration		1/8/2020 10:27:48 PM	1/8/2020 10:27 PM
Dates	Signed By Date	Insert	New Registration			1/8/2020 10:27 PM
Dates	Start Date	Insert	New Registration			1/8/2020 10:27 PM
Terminations	Termination Comments	Insert	New Registration			1/8/2020 10:27 PM
Terminations	Termination Date	Insert	New Registration			1/8/2020 10:27 PM
Terminations	Termination Effective Date	Insert	New Registration			1/8/2020 10:27 PM
Terminations	Termination Reason	Insert	New Registration			1/8/2020 10:27 PM