Covered Entity Details

DSH500079E GOOD SAMARITAN HOSPITAL (Active) - information as of 4/24/2025 10:09:13 PM

Main Details

Name

GOOD SAMARITAN HOSPITAL

Subdivision Name

Good Samaritan Diabetes and Nutrition Services - Diabetes

Type

Disproportionate Share Hospital

Rural

340B ID

DSH500079E

Medicare Provider Number

500079

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/5/2022

Participating Start Date

4/1/2022

Participating Approval Date

1/7/2022

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

MultiCare Health System
Timothy Wayne Lynch, Sr. VP, Chief Administrative Officer
(253) 403-2824

Primary Contact

MultiCare Health System
Cindy Wilson, Assistant Vice President - Pharmacy Compliance
(253) 403-2822

Addresses

Street Address

1323 3rd St. SE, Ground Floor
Puyallup, WA 98372

Billing Address

MultiCare Health System
PO Box 5299
MS 1313-5-AP
Tacoma, WA 98415-0299

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	3308707	1083655625,1841231461

Shipping Addresses

Shipping Address 1

Good Samaritan Diabetes and Nutrition Services
1323 3rd St. SE, Ground Floor
Puyallup, WA 98372

Shipping Address 2

MultiCare Good Samaritan Hospital
401 15th Ave SE
Puyallup, WA 98372

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
DSH500079A	Child	DSH	GOOD SAMARITAN HOSPITAL	MULTICARE GOOD SAMARITAN HOSPICE	3901 SOUTH FIFE STREET	TACOMA	WA	Active
DSH500079B	Child	DSH	GOOD SAMARITAN HOSPITAL	GSH PET/CT SCAN - GSH PET/CT SCAN	400 15th Avenue South East	Puyallup	WA	Active
DSH500079C	Child	DSH	GOOD SAMARITAN HOSPITAL	GSH DIABETES SRVCS - GSH DIABETES SRVCS	1322 3rd St SE	Puyallup	WA	Terminated
DSH500079D	Child	DSH	GOOD SAMARITAN HOSPITAL	GSH WOUND HEALING & HYPERBARIC SVCS - GSH WOUND HEALING & HYPERBARIC SVCS	400 15th Avenue SE	Puyallup	WA	Terminated
DSH500079E	Child	DSH	GOOD SAMARITAN HOSPITAL	Good Samaritan Diabetes and Nutrition Services - Diabetes	1323 3rd St. SE, Ground Floor	Puyallup	WA	Active
DSH500079F	Child	DSH	GOOD SAMARITAN HOSPITAL	MultiCare GSH Emergency Parkland - Emergency	14815 Pacific Ave S	Parkland	WA	Active
DSH500079G	Child	DSH	GOOD SAMARITAN HOSPITAL	Puyallup Pharmaceutical Resource Clinic (Anti-Coag) - Anticoagulation Clinic	1322 3rd St. SE, Suite #020	Puyallup	WA	Active
DSH500079H	Child	DSH	GOOD SAMARITAN HOSPITAL	MultiCare GSH South Hill Emergency - Emergency	13106 Meridian Ave E	Puyallup	WA	Active
DSH500079J	Child	DSH	GOOD SAMARITAN HOSPITAL	MultiCare GSH Emergency Bonney Lake - Emergency	9550 195th Ave E	Bonney Lake	WA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/5/2023 12:05:44 PM	8/18/2024 7:43:24 PM	8/18/2024 7:43 PM
Details	Last Recertification Date	Update	Recertification	9/17/2022 3:59:41 PM	9/5/2023 12:05:44 PM	9/5/2023 12:05 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1457629644 (WA)		12/13/2022 5:22 PM
Contacts	Authorizing Official	Update	AO Change Request	Chang, Florence President MULTICARE HEALTH SYSTEM 2534037355	Lynch, Timothy Wayne Sr. VP, Chief Administrative Officer MultiCare Health System 2534032824	11/7/2022 8:39 AM
Details	Last Recertification Date	Update	Recertification		9/17/2022 3:59:41 PM	9/17/2022 3:59 PM
Contacts	Authorizing Official	Update	Profile Change Request	Chang, Florence Executive Vice President MULTICARE HEALTH SYSTEM 2534037355	Chang, Florence President MULTICARE HEALTH SYSTEM 2534037355	4/18/2022 7:16 AM
Contacts	Signed By	Update	Profile Change Request	Chang, Florence Executive Vice President MULTICARE HEALTH SYSTEM 2534037355	Chang, Florence President MULTICARE HEALTH SYSTEM 2534037355	4/18/2022 7:16 AM
Contacts	Primary Contact	Update	Profile Change Request	Wilson, Cindy Executive Director Pharmacy Compliance MultiCare Health System 2534032822	Wilson, Cindy Assistant Vice President - Pharmacy Compliance MultiCare Health System 2534032822	4/15/2022 12:38 PM
Details	State	Update		Approved	Active	4/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Chang, Florence Executive Vice President MULTICARE HEALTH SYSTEM 2534037355	1/7/2022 10:14 AM
Details	340B ID	Update	New Registration		DSH500079E	1/7/2022 10:14 AM
Details	Entity Subname	Update	New Registration	Good Samaritan Diabetes and Nutrition Services	Good Samaritan Diabetes and Nutrition Services - Diabetes	1/7/2022 10:14 AM
Dates	Participating Approval Date	Update	New Registration		1/7/2022 10:14:52 AM	1/7/2022 10:14 AM
Details	State	Update	New Registration	Pending	Approved	1/7/2022 10:14 AM
Dates	Signed By Date	Update	New Registration		1/5/2022 6:56:56 PM	1/7/2022 10:14 AM
Dates	Start Date	Update	New Registration		4/1/2022 12:00:00 AM	1/7/2022 10:14 AM
Addresses	Main Address	Insert	New Registration		1323 3rd St. SE, Ground Floor Puyallup, WA 98372	1/5/2022 3:01 PM
Addresses	Billing Address	Insert	New Registration		MultiCare Health System PO Box 5299 MS 1313-5-AP Tacoma, WA 98415-0299	1/5/2022 3:01 PM
Addresses	Shipping Address	Insert	New Registration		Good Samaritan Diabetes and Nutrition Services 1323 3rd St. SE, Ground Floor Puyallup, WA 98372	1/5/2022 3:01 PM
Addresses	Shipping Address	Insert	New Registration		MultiCare Good Samaritan Hospital 401 15th Ave SE Puyallup, WA 98372	1/5/2022 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/5/2022 3:01 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3308707	1/5/2022 3:01 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WA	1/5/2022 3:01 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083655625	1/5/2022 3:01 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	1/5/2022 3:01 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457629644	1/5/2022 3:01 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	1/5/2022 3:01 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1841231461	1/5/2022 3:01 PM
Medicaid Billing	NPI: State	Insert	New Registration		WA	1/5/2022 3:01 PM
Contacts	Authorizing Official	Insert	New Registration		Chang, Florence Executive Vice President MULTICARE HEALTH SYSTEM 2534037355	1/5/2022 3:01 PM
Contacts	Primary Contact	Insert	New Registration		Wilson, Cindy Executive Director Pharmacy Compliance MultiCare Health System 2534032822	1/5/2022 3:01 PM
Details	Assistance Received From Date	Insert	New Registration			1/5/2022 3:01 PM
Details	Assistance Received To Date	Insert	New Registration			1/5/2022 3:01 PM
Details	Last Recertification Date	Insert	New Registration			1/5/2022 3:01 PM
Details	Grant Number	Insert	New Registration			1/5/2022 3:01 PM
Details	340B ID	Insert	New Registration			1/5/2022 3:01 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/5/2022 3:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/5/2022 3:01 PM
Details	Medicare Provider Number	Insert	New Registration		500079	1/5/2022 3:01 PM
Details	Entity Name	Insert	New Registration		GOOD SAMARITAN HOSPITAL	1/5/2022 3:01 PM
Details	NOFO Number	Insert	New Registration			1/5/2022 3:01 PM
Details	Program Code	Insert	New Registration		DSH	1/5/2022 3:01 PM
Details	Entity Subname	Insert	New Registration		Good Samaritan Diabetes and Nutrition Services	1/5/2022 3:01 PM
Dates	Participating Approval Date	Insert	New Registration			1/5/2022 3:01 PM
Details	State	Insert	New Registration		Pending	1/5/2022 3:01 PM
Dates	Registration Date	Insert	New Registration		1/5/2022 3:01:50 PM	1/5/2022 3:01 PM
Dates	Signed By Date	Insert	New Registration			1/5/2022 3:01 PM
Dates	Start Date	Insert	New Registration			1/5/2022 3:01 PM
Terminations	Termination Comments	Insert	New Registration			1/5/2022 3:01 PM
Terminations	Termination Date	Insert	New Registration			1/5/2022 3:01 PM
Terminations	Termination Effective Date	Insert	New Registration			1/5/2022 3:01 PM
Terminations	Termination Reason	Insert	New Registration			1/5/2022 3:01 PM