Covered Entity Details

DSH220052AG BROCKTON HOSPITAL, INC (ToBeTerminated) - information as of 5/24/2025 12:45:21 AM

Main Details

Name

BROCKTON HOSPITAL, INC

Subdivision Name

BH Pain Clinic Hanson - Pain Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220052AG

Medicare Provider Number

220052

Outpatient Facility Provider Number

Additional Details

Current Program Status

ToBeTerminated

Registration Date

4/3/2024

Participating Start Date

7/1/2024

Participating Approval Date

4/11/2024

Last Recertification Date

8/16/2024

Termination Date
Termination Reason

7/1/2025
Outpatient facility moved within the 4 walls of the parent hospital

Contacts

Authorizing Official

Brockton Hospital
Margaret Clapp, Enterprise Director of Pharmacy
(508) 941-7750

Primary Contact

Signature Healthcare Brockton Hospital
Christine Canty, 340B Business Operations Manager
(508) 941-7186

Addresses

Street Address

430 Liberty Street
Suite 7
Hanson, MA 02341

Billing Address

Signature Healthcare Brockton Hospital, Inc.
680 Centre Street
Brockton, MA 02302

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
MA	110026502C	1063431286

Shipping Addresses

Shipping Address 1

Signature Healhcare Brockton Hospital, Inc.
680 Centre Street
Brockton, MA 02302

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
DSH220052A	Child	DSH	BROCKTON HOSPITAL, INC	Clinic	130 Quincy Avenue	Brockton	MA	Active
DSH220052AA	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital-BH CT Scan - BH CT Scan	110 Liberty Street	Brockton	MA	Active
DSH220052AB	Child	DSH	BROCKTON HOSPITAL, INC	Green Cancer Center-Surgery Clinic - Surgery Clinic	25 Libby Street	Brockton	MA	Active
DSH220052AC	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center- BH R ECHO LAB - BH R ECHO LAB	25 Libby Street	Brockton	MA	ToBeTerminated
DSH220052AD	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center- BH NUCMED - BH R NUC Hospital	25 Libby Street	Brockton	MA	ToBeTerminated
DSH220052AE	Child	DSH	BROCKTON HOSPITAL, INC	BH Raynham Eye Services - Eye Services	1215 Broadway	Raynham	MA	Active
DSH220052AF	Child	DSH	BROCKTON HOSPITAL, INC	BH Urgent Care 650 Centre - Urgent Care	650 Centre Street	Brockton	MA	Terminated
DSH220052AG	Child	DSH	BROCKTON HOSPITAL, INC	BH Pain Clinic Hanson - Pain Clinic	430 Liberty Street	Hanson	MA	ToBeTerminated
DSH220052AH	Child	DSH	BROCKTON HOSPITAL, INC	BH Urgent Care Liberty - Urgent Care	110 Liberty Street	Brockton	MA	Terminated
DSH220052AJ	Child	DSH	BROCKTON HOSPITAL, INC	BH Rad Hanson - Radiology	430 Liberty Street	Hanson	MA	ToBeTerminated
DSH220052AK	Child	DSH	BROCKTON HOSPITAL, INC	BH Pulmonary Clinic EB - Pulmonary	1 Donald's Way	East Bridgewater	MA	Approved
DSH220052AL	Child	DSH	BROCKTON HOSPITAL, INC	BH DERMATOLOG CLINIC EB - Dermatology	1 Donald's Way	East Bridgewater	MA	Approved
DSH220052AM	Child	DSH	BROCKTON HOSPITAL, INC	BH IM CLINIC EB - Internal Medicine	1 Donald's Way	East Bridgewater	MA	Approved
DSH220052AN	Child	DSH	BROCKTON HOSPITAL, INC	BH FP CLINIC EB - Family Medicine Practice	1 Donald's Way	East Bridgewater	MA	Approved
DSH220052B	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Signature Healthcare Cancer Treatment Center	25 Libby Street	Brockton	MA	Active
DSH220052C	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital Raynham Internal Medicine - Internal Medicine	1215 Broadway	Raynham	MA	Terminated
DSH220052D	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center - Cardiology Services	25 Libby Street	Brockton	MA	Active
DSH220052E	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Rheumatology Clinic OPD - Rheumatology Clinic OPD	130 Quincy Avenue	Brockton	MA	Terminated
DSH220052F	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Gastroenterology Clinic OPD - Gastroenterology Clinic OPD	130 Quincy Avenue	Brockton	MA	Terminated
DSH220052G	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - BH Raynham FP Clinic - Raynham Family Practice Clinic	1215 Broadway	Raynham	MA	Active
DSH220052H	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center- Pulmonology Clinic - Pulmonology	25 Libby Street	Brockton	MA	Active
DSH220052J	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Infectious Disease OPD - Infectious Disease - OPD	130 Quincy Avenue	Brockton	MA	Active
DSH220052K	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Endocrinology Clinic OPD - Endocrinology Clinic OPD	130 Quincy Avenue	Brockton	MA	Terminated
DSH220052L	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Raynham Pediatric Clinic - Raynham Pediatric Clinic	1215 Broadway	Raynham	MA	Terminated
DSH220052M	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center-Endocrinology Clinic - Endocrine	25 Libby Street	Brockton	MA	Active
DSH220052N	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital - Liberty DPH Dermatology Clinic	110 Liberty Street 2nd Floor	Brockton	MA	Active
DSH220052P	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center-Plastic Clinic - Plastic Clinic	25 Libby Street	Brockton	MA	Active
DSH220052Q	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Endocrinology Clinic Liberty - BH Endo Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052R	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Same Day Clinic Liberty - BH Same Day Clin Liberty	110 Liberty Street	Brockton	MA	Terminated
DSH220052S	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Pulmonology Clinic Liberty - BH Pulm Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052T	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Nephrology Clinic Liberty - BH Nephr Clinic Liberty	110 Liberty St	Brockton	MA	Active
DSH220052U	Child	DSH	BROCKTON HOSPITAL, INC	Greene Cancer Center-BH Thoracic Surgery - BH Thor Surg Clinic Libby	25 Libby St	Brockton	MA	Active
DSH220052V	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Internal Med Clinic Liberty - BH IM Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052W	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Rheumatology Clinic Liberty - BH Rheum Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052X	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Neurology Clinic Liberty - BH Neuro Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052Y	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital –Bariatric Clinic Liberty - BH Bariat Clinic Liberty	110 Liberty Street	Brockton	MA	Active
DSH220052Z	Child	DSH	BROCKTON HOSPITAL, INC	Signature Healthcare Brockton Hospital-BH Family Practice - BH FP Clinic Liberty	110 Liberty St	Brockton	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		4/30/2025 12:00:00 AM	5/7/2025 11:10 AM
Details	State	Update	Termination Request	Active	To Be Terminated	5/7/2025 11:10 AM
Terminations	Termination Date	Update	Termination Request		7/1/2025 12:00:00 AM	5/7/2025 11:10 AM
Terminations	Termination Effective Date	Update	Termination Request		5/6/2025 12:00:00 AM	5/7/2025 11:10 AM
Terminations	Termination Reason	Update	Termination Request		Outpatient facility moved within the 4 walls of the parent hospital	5/7/2025 11:10 AM
Contacts	Primary Contact	Update	Recertification	Clapp, Margaret Enterprise Director of Pharmacy Brockton Hospital 5089417750	Canty, Christine 340B Business Operations Manager Signature Healthcare Brockton Hospital 5089417186	8/16/2024 9:35 AM
Details	Last Recertification Date	Update	Recertification		8/16/2024 9:35:28 AM	8/16/2024 9:35 AM
Contacts	Authorizing Official	Update	Change Request	Borges, Stephen Vice President, Finance Operations Brockton Hospital 5089417571	Clapp, Margaret Enterprise Director of Pharmacy Brockton Hospital 5089417750	8/5/2024 6:54 AM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Borges, Stephen Vice President, Finance Operations Brockton Hospital 5089417571	4/11/2024 12:04 PM
Details	340B ID	Update	New Registration		DSH220052AG	4/11/2024 12:04 PM
Details	Entity Name	Update	New Registration	BROCKTON HOSPITAL INC.	BROCKTON HOSPITAL, INC	4/11/2024 12:04 PM
Details	Entity Subname	Update	New Registration	BH Pain Clinic Hanson	BH Pain Clinic Hanson - Pain Clinic	4/11/2024 12:04 PM
Dates	Participating Approval Date	Update	New Registration		4/11/2024 12:04:15 PM	4/11/2024 12:04 PM
Details	State	Update	New Registration	Pending	Approved	4/11/2024 12:04 PM
Dates	Signed By Date	Update	New Registration		4/8/2024 4:35:05 PM	4/11/2024 12:04 PM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	4/11/2024 12:04 PM
Addresses	Main Address	Insert	New Registration		430 Liberty Street Suite 7 Hanson, MA 02341	4/3/2024 12:06 PM
Addresses	Billing Address	Insert	New Registration		Signature Healthcare Brockton Hospital, Inc. 680 Centre Street Brockton, MA 02302	4/3/2024 12:06 PM
Addresses	Shipping Address	Insert	New Registration		Signature Healhcare Brockton Hospital, Inc. 680 Centre Street Brockton, MA 02302	4/3/2024 12:06 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2024 12:06 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026502C	4/3/2024 12:06 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/3/2024 12:06 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1063431286	4/3/2024 12:06 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/3/2024 12:06 PM
Contacts	Primary Contact	Insert	New Registration		Clapp, Margaret Enterprise Director of Pharmacy Brockton Hospital 5089417750	4/3/2024 12:06 PM
Contacts	Authorizing Official	Insert	New Registration		Borges, Stephen Vice President, Finance Operations Brockton Hospital 5089417571	4/3/2024 12:06 PM
Details	Assistance Received From Date	Insert	New Registration			4/3/2024 12:06 PM
Details	Assistance Received To Date	Insert	New Registration			4/3/2024 12:06 PM
Details	Last Recertification Date	Insert	New Registration			4/3/2024 12:06 PM
Details	Grant Number	Insert	New Registration			4/3/2024 12:06 PM
Details	340B ID	Insert	New Registration			4/3/2024 12:06 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/3/2024 12:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/3/2024 12:06 PM
Details	Medicare Provider Number	Insert	New Registration		220052	4/3/2024 12:06 PM
Details	Entity Name	Insert	New Registration		BROCKTON HOSPITAL INC.	4/3/2024 12:06 PM
Details	NOFO Number	Insert	New Registration			4/3/2024 12:06 PM
Details	Program Code	Insert	New Registration		DSH	4/3/2024 12:06 PM
Details	Entity Subname	Insert	New Registration		BH Pain Clinic Hanson	4/3/2024 12:06 PM
Dates	Participating Approval Date	Insert	New Registration			4/3/2024 12:06 PM
Details	State	Insert	New Registration		Pending	4/3/2024 12:06 PM
Dates	Registration Date	Insert	New Registration		4/3/2024 12:06:02 PM	4/3/2024 12:06 PM
Dates	Signed By Date	Insert	New Registration			4/3/2024 12:06 PM
Dates	Start Date	Insert	New Registration			4/3/2024 12:06 PM
Terminations	Termination Comments	Insert	New Registration			4/3/2024 12:06 PM
Terminations	Termination Date	Insert	New Registration			4/3/2024 12:06 PM
Terminations	Termination Effective Date	Insert	New Registration			4/3/2024 12:06 PM
Terminations	Termination Reason	Insert	New Registration			4/3/2024 12:06 PM