Covered Entity Details

DSH330057 ST. PETERS HOSPITAL (Active) - information as of 6/12/2025 6:02:33 AM

Main Details

Name

ST. PETERS HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330057

Medicare Provider Number

330057

Additional Details

Current Program Status

Active

Registration Date

1/15/2024

Participating Start Date

4/1/2024

Participating Approval Date

1/26/2024

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Samaritan Hospital of Troy NY
Lori Santos, CFO
(518) 525-5537

Primary Contact

Saint Peters Hospital Albany NY
John Joseph Faccone, Trinity NY Regional 340B Manager
(518) 326-7510

Addresses

Street Address

315 S. MANNING BLVD.
ALBANY, NY 12208

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

Shipping Address 1

ST. PETERS HOSPITAL
315 S. MANNING BLVD.
ALBANY, NY 12208

Shipping Address 2

SAFECOR
317 New Boston St.
Woburn, MA 01801

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CVS ALBANY, L.L.C.	DBA: CVS/PHARMACY # 05456	2027 DOUBLEDAY AVE.	BALLSTON SPA	NY	12020	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CVS ALBANY, L.L.C.	DBA: CVS/PHARMACY # 00134	16 NEW SCOTLAND AVE.	ALBANY	NY	12208	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CVS ALBANY, L.L.C.	DBA: CVS/PHARMACY # 00375	260 DELAWARE AVENUE	DELMAR	NY	12054	04/09/2025	07/01/2025	04/09/2025
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/09/2025	07/01/2025	04/09/2025
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/09/2025	07/01/2025	04/09/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/09/2025	07/01/2025	04/09/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	CVS/PHARMACY #48637	2700 NORTHEAST EXPY NE STE B800 BUILDING B	ATLANTA	GA	30345	04/09/2025	07/01/2025	04/09/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/09/2025	07/01/2025	04/09/2025
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/09/2025	07/01/2025	04/09/2025
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/09/2025	07/01/2025	04/09/2025
Contract Detail	TRINITY HEALTH PHARMACY SERVICES, LLC	12279 BLUFFTON RD		FORT WAYNE	IN	46809-3208	04/09/2024	07/01/2024	07/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330057A	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Radiology	1365 WASHINGTON AVE	ALBANY	NY	Active
DSH330057B	Child	DSH	ST. PETERS HOSPITAL	St Peter's Hospital Radiation Oncology - Radiation Oncology	317 S Manning Blvd	Albany	NY	Active
DSH330057C	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Physical Medicine and Rehabilitation	1182 TROY SCHENECTADY RD	LATHAM	NY	Active
DSH330057D	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Chemical Dependency	125 HIGH ROCK AVE	SARATOGA SPRINGS	NY	Active
DSH330057E	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Chemical Dependency	64 2ND AVE	ALBANY	NY	Active
DSH330057F	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Chemical Dependency	2925 HAMBURG ST	SCHENECTADY	NY	Active
DSH330057G	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Chemical Dependency	636 NEW LOUDON RD	LATHAM	NY	Active
DSH330057H	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Chemical Dependency	55 MOHAWK ST	COHOES	NY	Active
DSH330057J	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Obstetrics and Gynecology	326 S PEARL ST	ALBANY	NY	Active
DSH330057K	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Pediatrics	326 S PEARL ST	ALBANY	NY	Active
DSH330057L	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Internal Medicine	326 S PEARL ST	ALBANY	NY	Active
DSH330057M	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Family Medicine	53 COLUMBIA ST	RENSSELAER	NY	Active
DSH330057N	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Sleep Medicine	1 PINE WEST PLZ	ALBANY	NY	Active
DSH330057P	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Hematology Oncology Infusion Therapy	317 S MANNING BLVD	ALBANY	NY	Active
DSH330057Q	Child	DSH	ST. PETERS HOSPITAL	ST PETERS HOSPITAL OF THE CITY OF A - Neurosurgery	1182 TROY SCHENECTADY RD	LATHAM	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/19/2024 10:02:40 AM	8/19/2024 10:02 AM
Addresses	Shipping Address	Update	Change Request	SAFECOR 317 New Boston St. STE 100 Woburn, MA 01801	SAFECOR 317 New Boston St. Woburn, MA 01801	5/28/2024 8:44 AM
Addresses	Shipping Address	Insert	Change Request		ST. PETERS HOSPITAL 315 S. MANNING BLVD. ALBANY, NY 12208	4/1/2024 6:23 AM
Addresses	Shipping Address	Insert	Change Request		SAFECOR 317 New Boston St. STE 100 Woburn, MA 01801	4/1/2024 6:23 AM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Santos, Lori CFO Samaritan Hospital of Troy NY 5185255537	1/26/2024 7:55 AM
Details	340B ID	Update	New Registration		DSH330057	1/26/2024 7:55 AM
Dates	Participating Approval Date	Update	New Registration		1/26/2024 7:55:16 AM	1/26/2024 7:55 AM
Details	State	Update	New Registration	Pending	Approved	1/26/2024 7:55 AM
Dates	Signed By Date	Update	New Registration		1/15/2024 3:56:17 PM	1/26/2024 7:55 AM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	1/26/2024 7:55 AM
Addresses	Main Address	Insert	New Registration		315 S. MANNING BLVD. ALBANY, NY 12208	1/15/2024 1:00 PM
Contacts	Authorizing Official	Insert	New Registration		Santos, Lori CFO Samaritan Hospital of Troy NY 5185255537	1/15/2024 1:00 PM
Contacts	Primary Contact	Insert	New Registration		Faccone, John Joseph Trinity NY Regional 340B Manager Saint Peters Hospital Albany NY 5183267510	1/15/2024 1:00 PM
Details	Assistance Received From Date	Insert	New Registration			1/15/2024 1:00 PM
Details	Assistance Received To Date	Insert	New Registration			1/15/2024 1:00 PM
Details	Last Recertification Date	Insert	New Registration			1/15/2024 1:00 PM
Details	Grant Number	Insert	New Registration			1/15/2024 1:00 PM
Details	340B ID	Insert	New Registration			1/15/2024 1:00 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2024 1:00 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2024 1:00 PM
Details	Medicare Provider Number	Insert	New Registration		330057	1/15/2024 1:00 PM
Details	Entity Name	Insert	New Registration		ST. PETERS HOSPITAL	1/15/2024 1:00 PM
Details	NOFO Number	Insert	New Registration			1/15/2024 1:00 PM
Details	Program Code	Insert	New Registration		DSH	1/15/2024 1:00 PM
Details	Entity Subname	Insert	New Registration			1/15/2024 1:00 PM
Dates	Participating Approval Date	Insert	New Registration			1/15/2024 1:00 PM
Details	State	Insert	New Registration		Pending	1/15/2024 1:00 PM
Dates	Registration Date	Insert	New Registration		1/15/2024 1:00:11 PM	1/15/2024 1:00 PM
Dates	Signed By Date	Insert	New Registration			1/15/2024 1:00 PM
Dates	Start Date	Insert	New Registration			1/15/2024 1:00 PM
Terminations	Termination Comments	Insert	New Registration			1/15/2024 1:00 PM
Terminations	Termination Date	Insert	New Registration			1/15/2024 1:00 PM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2024 1:00 PM
Terminations	Termination Reason	Insert	New Registration			1/15/2024 1:00 PM