Covered Entity Details

SCH390048-11 GEISINGER LEWISTOWN HOSPITAL (Terminated) - information as of 6/27/2025 12:30:36 AM

Main Details

Name

GEISINGER LEWISTOWN HOSPITAL

Subdivision Name

GEISINGER LEWISTOWN HOSPITAL - MR Imaging Mifflintown

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH390048-11

Medicare Provider Number

390048

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/15/2024

Participating Start Date

4/1/2024

Participating Approval Date

3/6/2024

Last Recertification Date

8/16/2024

Termination Date
Termination Reason

1/1/2025
Change of covered entity type

Contacts

Authorizing Official

Geisinger Health
Michael Anthony Evans, VP Pharmacy CPO
(570) 271-6192

Primary Contact

Geisinger Health
Lola Travelpiece, 340B Program Manager
(570) 214-1035

Addresses

Street Address

27 CJEMS LANE
GEISINGER RADIOLOGY MIFFLINTOWN, A SERVICE OF GLH
MIFFLINTOWN, PA 17059-8384

Billing Address

Geisinger Lewistown Hospital
400 Highland Ave
Lewistown, PA 17044

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
PA	1007506760004,1007506760023,1007506760041,1007506760043,1007506760045,1007506760046,1007506760050	1497338313,1609263946,1639560550,1750778981,1801531322,1841970746,1861545683

Shipping Addresses

Shipping Address 1

Geisinger Lewistown Hospital
400 Highland Ave
Lewistown, PA 17044

Shipping Address 2

Geisinger System Services Distribution Center
212 Industrial Park Rd
Elysburg, PA 17824

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
SCH390048-01	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - Rad Oncology Tech	211 3RD ST	LEWISTOWN	PA	Terminated
SCH390048-02	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - Gen Diagnostics RAD JVMC	27 CJEMS LANE	MIFFLINTOWN	PA	Terminated
SCH390048-03	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - Cat Scanner JVMC Mobile	27 CJEMS LANE	MIFFLINTOWN	PA	Terminated
SCH390048-04	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - Ultrasound JVMC mobile	27 CJEMS LANE	MIFFLINTOWN	PA	Terminated
SCH390048-05	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - MRI JVMC Mobile	27 CJEMS LANE	MIFFLINTOWN	PA	Terminated
SCH390048-06	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	Geisinger Lewistown Hospital - Infectious Disease ACC	310 Electric Ave	Lewistown	PA	Terminated
SCH390048-07	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	Geisinger Lewistown Hospital - Gastro Electric Ave	310 Electric Ave	Lewistown	PA	Terminated
SCH390048-08	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - CT Imaging MIfflintown	27 CJEMS LANE	MIFFLINTOWN	PA	Terminated
SCH390048-09	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL ENDO - Endo GECL	310 ELECTRIC AVE	LEWISTOWN	PA	Terminated
SCH390048-10	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - OR OSSC	132 ABIGAIL LN	PORT MATILDA	PA	Terminated
SCH390048-11	Child	SCH	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - MR Imaging Mifflintown	27 CJEMS LANE	MIFFLINTOWN	PA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	12/10/2024 11:36 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	12/10/2024 11:36 AM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	12/10/2024 11:36 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	12/10/2024 11:36 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	12/10/2024 11:36 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007506760004 (PA)		8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007506760008 (PA)		8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007506760023 (PA)		8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007506760041 (PA)		8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007506760042 (PA)		8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007506760043 (PA)		8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007506760045 (PA)		8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007506760004	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007506760023	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007506760041	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007506760043	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007506760045	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007506760046	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007506760050	8/16/2024 7:03 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1497338313 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1558486928 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1609263946 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1639560550 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1689061921 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1750778981 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1801531322 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1831242114 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1841970746 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1861545683 (PA)		8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1497338313	8/16/2024 7:03 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1609263946	8/16/2024 7:03 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1639560550	8/16/2024 7:03 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1750778981	8/16/2024 7:03 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1801531322	8/16/2024 7:03 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841970746	8/16/2024 7:03 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1861545683	8/16/2024 7:03 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/16/2024 7:03 AM
Details	Last Recertification Date	Update	Recertification		8/16/2024 7:03:39 AM	8/16/2024 7:03 AM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Evans, Michael Anthony VP Pharmacy CPO Geisinger Health 5702716192	3/6/2024 8:17 AM
Details	340B ID	Update	New Registration		SCH390048-11	3/6/2024 8:17 AM
Details	Entity Subname	Update	New Registration	GEISINGER LEWISTOWN HOSPITAL	GEISINGER LEWISTOWN HOSPITAL - MR Imaging Mifflintown	3/6/2024 8:17 AM
Dates	Participating Approval Date	Update	New Registration		3/6/2024 8:17:25 AM	3/6/2024 8:17 AM
Details	State	Update	New Registration	Pending	Approved	3/6/2024 8:17 AM
Dates	Signed By Date	Update	New Registration		1/16/2024 7:34:00 AM	3/6/2024 8:17 AM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	3/6/2024 8:17 AM
Addresses	Main Address	Insert	New Registration		27 CJEMS LANE GEISINGER RADIOLOGY MIFFLINTOWN, A SERVICE OF GLH MIFFLINTOWN, PA 17059-8384	1/15/2024 5:34 PM
Addresses	Billing Address	Insert	New Registration		Geisinger Lewistown Hospital 400 Highland Ave Lewistown, PA 17044	1/15/2024 5:34 PM
Addresses	Shipping Address	Insert	New Registration		Geisinger Lewistown Hospital 400 Highland Ave Lewistown, PA 17044	1/15/2024 5:34 PM
Addresses	Shipping Address	Insert	New Registration		Geisinger System Services Distribution Center 212 Industrial Park Rd Elysburg, PA 17824	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007506760004	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007506760008	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007506760023	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007506760041	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007506760042	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007506760043	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007506760045	1/15/2024 5:34 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1497338313	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1558486928	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1609263946	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1639560550	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1689061921	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1750778981	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1801531322	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1831242114	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1841970746	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1861545683	1/15/2024 5:34 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	1/15/2024 5:34 PM
Contacts	Authorizing Official	Insert	New Registration		Evans, Michael Anthony VP Pharmacy CPO Geisinger Health 5702716192	1/15/2024 5:34 PM
Contacts	Primary Contact	Insert	New Registration		Travelpiece, Lola 340B Program Manager Geisinger Health 5702141035	1/15/2024 5:34 PM
Details	Assistance Received From Date	Insert	New Registration			1/15/2024 5:34 PM
Details	Assistance Received To Date	Insert	New Registration			1/15/2024 5:34 PM
Details	Last Recertification Date	Insert	New Registration			1/15/2024 5:34 PM
Details	Grant Number	Insert	New Registration			1/15/2024 5:34 PM
Details	340B ID	Insert	New Registration			1/15/2024 5:34 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2024 5:34 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2024 5:34 PM
Details	Medicare Provider Number	Insert	New Registration		390048	1/15/2024 5:34 PM
Details	Entity Name	Insert	New Registration		GEISINGER LEWISTOWN HOSPITAL	1/15/2024 5:34 PM
Details	NOFO Number	Insert	New Registration			1/15/2024 5:34 PM
Details	Program Code	Insert	New Registration		SCH	1/15/2024 5:34 PM
Details	Entity Subname	Insert	New Registration		GEISINGER LEWISTOWN HOSPITAL	1/15/2024 5:34 PM
Dates	Participating Approval Date	Insert	New Registration			1/15/2024 5:34 PM
Details	State	Insert	New Registration		Pending	1/15/2024 5:34 PM
Dates	Registration Date	Insert	New Registration		1/15/2024 5:34:19 PM	1/15/2024 5:34 PM
Dates	Signed By Date	Insert	New Registration			1/15/2024 5:34 PM
Dates	Start Date	Insert	New Registration			1/15/2024 5:34 PM
Terminations	Termination Comments	Insert	New Registration			1/15/2024 5:34 PM
Terminations	Termination Date	Insert	New Registration			1/15/2024 5:34 PM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2024 5:34 PM
Terminations	Termination Reason	Insert	New Registration			1/15/2024 5:34 PM