| Contacts | Primary Contact | Update | Group Change Request | Hanson, Victoria Marie
Regional Pharmacy 340B Manager
Providence St Joseph Health
7076722135 | Peterson, Jesse
340B Program Director, South Division
Providence
6513242207 | 11/1/2024 1:16 PM |
| Contacts | Authorizing Official | Update | Change Request | Naotunne, Bharatha
CFO
NorCal Health Connect
7074316523 | Wright, Erika
CFO
Providence St Joseph Health
7075255300 | 10/24/2024 8:38 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1194824573 (CA) | | 8/12/2024 8:17 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1861009672 | 8/12/2024 8:17 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 8/12/2024 8:17 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2023 2:05:25 PM | 8/12/2024 8:17:45 PM | 8/12/2024 8:17 PM |
| Addresses | Main Address | Update | Change Request |
1310 Prentice Drive
Suite A
Healdsburg, CA 95448 |
1312 Prentice Drive
Healdsburg, CA 95448 | 10/17/2023 7:49 AM |
| Addresses | Billing Address | Update | Change Request | Healdsburg District Hospital
1375 University Avenue
Healdsburg, CA 95448 | Healdsburg Hospital
1375 University Avenue
Healdsburg, CA 95448 | 10/17/2023 7:49 AM |
| Addresses | Shipping Address | Insert | Change Request | | Healdsburg Hospital
1375 University Avenue
Healdsburg, CA 95448 | 10/17/2023 7:49 AM |
| Details | Entity Subname | Update | Change Request | Healdsburg District Hospital Behavioral Health Services - Behavioral Health Services | Healdsburg Hospital Behavioral Health Services | 10/17/2023 7:49 AM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2022 11:48:27 AM | 9/7/2023 2:05:25 PM | 9/7/2023 2:05 PM |
| Contacts | Authorizing Official | Update | Change Request | Pilgrim, Patti
Regional CFO
Providence St. Joseph Health
7075255323 | Naotunne, Bharatha
CFO
NorCal Health Connect
7074316523 | 4/26/2023 2:35 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1194824573 | 9/6/2022 11:48 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | CA | 9/6/2022 11:48 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 3:00:41 PM | 9/6/2022 11:48:27 AM | 9/6/2022 11:48 AM |
| Details | Entity Name | Update | Change Request | HEALDSBURG DISTRICT HOSPITAL | NorCal HealthConnect LLC- DBA Healdsburg Hospital | 7/19/2022 12:48 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Hanson, Victoria Marie
340B Program Manager Northern CA Region
Providence St Joseph Health
7076722135 | Hanson, Victoria Marie
Regional Pharmacy 340B Manager
Providence St Joseph Health
7076722135 | 1/15/2022 2:52 PM |
| Details | Last Recertification Date | Update | Recertification | | 8/27/2021 3:00:41 PM | 8/27/2021 3:00 PM |
| Contacts | Authorizing Official | Update | Change Request | Kaemmerling, Berta Beadel
Chief Nursing Officer
Healdsburg
7074316327 | Pilgrim, Patti
Regional CFO
Providence St. Joseph Health
7075255323 | 4/8/2021 1:35 PM |
| Contacts | Primary Contact | Update | Change Request | LE, MYTRANG
DOP
HEALDSBURG DISTRICT HOSPITAL
7074316432 | Hanson, Victoria Marie
340B Program Manager Northern CA Region
Providence St Joseph Health
7076722135 | 4/8/2021 10:26 AM |
| Details | State | Update | | Approved | Active | 10/1/2020 12:01 AM |
| Contacts | Signed By | Insert | New Registration | | Kaemmerling, Berta Beadel
Chief Nursing Officer
Healdsburg
7074316327 | 9/9/2020 11:34 AM |
| Details | 340B ID | Update | New Registration | | CAH051321-04 | 9/9/2020 11:34 AM |
| Details | Entity Subname | Update | New Registration | Healdsburg District Hospital Behavioral Health Services | Healdsburg District Hospital Behavioral Health Services - Behavioral Health Services | 9/9/2020 11:34 AM |
| Dates | Participating Approval Date | Update | New Registration | | 9/9/2020 11:34:33 AM | 9/9/2020 11:34 AM |
| Details | State | Update | New Registration | Pending | Approved | 9/9/2020 11:34 AM |
| Dates | Signed By Date | Update | New Registration | | 9/7/2020 12:58:30 PM | 9/9/2020 11:34 AM |
| Dates | Start Date | Update | New Registration | | 10/1/2020 12:00:00 AM | 9/9/2020 11:34 AM |
| Addresses | Main Address | Insert | New Registration | |
1310 Prentice Drive
Suite A
Healdsburg, CA 95448 | 8/31/2020 6:40 PM |
| Addresses | Billing Address | Insert | New Registration | | Healdsburg District Hospital
1375 University Avenue
Healdsburg, CA 95448 | 8/31/2020 6:40 PM |
| Contacts | Primary Contact | Insert | New Registration | | LE, MYTRANG
DOP
HEALDSBURG DISTRICT HOSPITAL
7074316432 | 8/31/2020 6:40 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Kaemmerling, Berta Beadel
Chief Nursing Officer
Healdsburg
7074316327 | 8/31/2020 6:40 PM |
| Contacts | Authorizing Official | Update | New Registration | Kaemmerling, Berta Beadel
Chief Nursing Officer
Healdsburg
7074316327 | Kaemmerling, Berta Beadel
Chief Nursing Officer
Healdsburg
7074316327 | 8/31/2020 6:40 PM |
| Details | Assistance Received From Date | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Details | Assistance Received To Date | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Details | Grant Number | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Details | 340B ID | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 051321 | 8/31/2020 6:40 PM |
| Details | Entity Name | Insert | New Registration | | HEALDSBURG DISTRICT HOSPITAL | 8/31/2020 6:40 PM |
| Details | NOFO Number | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Details | Program Code | Insert | New Registration | | CAH | 8/31/2020 6:40 PM |
| Details | Entity Subname | Insert | New Registration | | Healdsburg District Hospital Behavioral Health Services | 8/31/2020 6:40 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Details | State | Insert | New Registration | | Pending | 8/31/2020 6:40 PM |
| Dates | Registration Date | Insert | New Registration | | 8/31/2020 6:40:05 PM | 8/31/2020 6:40 PM |
| Dates | Signed By Date | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Dates | Start Date | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Terminations | Termination Date | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 8/31/2020 6:40 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 8/31/2020 6:40 PM |