Covered Entity Details

DSH070006G THE STAMFORD HOSPITAL (Active) - information as of 4/25/2025 8:34:25 PM

Main Details

Name

THE STAMFORD HOSPITAL

Subdivision Name

Diabetes & Endocrine -LRR - Diabetes Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070006G

Medicare Provider Number

070006

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/8/2024

Participating Start Date

7/1/2024

Participating Approval Date

4/19/2024

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

Stamford Health
Ellen Komar, CNO & Sr VP -Patient Services
(203) 276-7401 Ext: 7401

Primary Contact

Stamford Hospital
Prudence Manirakiza, Pharmacy Business Manager
(203) 276-4232 Ext: 4232

Addresses

Street Address

292 Long Ridge Road
Suite 206
Stamford, CT 06902-1627

Billing Address

The Stamford Hospital
1 Hospital Plaza
Stamford, CT 06902

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
CT	004024964	1356331425
NY	350587	1356331425
NJ	5459109	1356331425
MD	14095300	1356331425
MA	110026981B	1356331425
FL	0937185-00	1356331425
NC	1356331425	1356331425
CA	1356331425	1356331425

Shipping Addresses

Same as Street Address

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
DSH070006A	Child	DSH	THE STAMFORD HOSPITAL	TULLY IMMEDIATE CARE CENTER	32 STRAWBERRY HILL CT	STAMFORD	CT	Active
DSH070006B	Child	DSH	THE STAMFORD HOSPITAL	TULLY SURGICAL CENTER	32 STRAWBERRY HILL COURT	STAMFORD	CT	Active
DSH070006C	Child	DSH	THE STAMFORD HOSPITAL	TULLY ENDOSCOPY CENTER - Endoscopy	32 Strawberry Hill Court	Stamford	CT	Active
DSH070006D	Child	DSH	THE STAMFORD HOSPITAL	INFUSION CENTER - Infusion Center - IV Therapy	One Hospital Plaza	Stamford	CT	Active
DSH070006E	Child	DSH	THE STAMFORD HOSPITAL	Ambulatory Care Center - Specialty Clinic	1351 Washington Blvd	Stamford	CT	Active
DSH070006F	Child	DSH	THE STAMFORD HOSPITAL	Gastroenterology -Tully - Gastroenterology	1351 Washington Blvd	Stamford	CT	Active
DSH070006G	Child	DSH	THE STAMFORD HOSPITAL	Diabetes & Endocrine -LRR - Diabetes Center	292 Long Ridge Road	Stamford	CT	Active
DSH070006H	Child	DSH	THE STAMFORD HOSPITAL	Rheumatology & Primary Care -LRR - Rheumatology & Primary Care	292 Long Ridge Road	Stamford	CT	Active
DSH070006J	Child	DSH	THE STAMFORD HOSPITAL	Pulmonary -Integrated Care Pavilion - Pulmonary	29 Hospital Plaza	Stamford	CT	Active
DSH070006K	Child	DSH	THE STAMFORD HOSPITAL	Infectious Disease -Integrated Care Pavilion - Infectious Diseases	29 Hospital Plaza	Stamford	CT	Active
DSH070006L	Child	DSH	THE STAMFORD HOSPITAL	Cardiology -Integrated Care Pavilion - Cardiology	29 Hospital Plaza	Stamford	CT	Active
DSH070006M	Child	DSH	THE STAMFORD HOSPITAL	Neurology -Integrated Care Pavilion - Neurology	29 Hospital Plz	Stamford	CT	Active
DSH070006N	Child	DSH	THE STAMFORD HOSPITAL	Neurology -Chelsea Piers - Neurology	1 Blachley Road	Stamford	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/23/2024 8:58 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1356331425	8/23/2024 8:58 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/23/2024 8:58 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1356331425	8/23/2024 8:58 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/23/2024 8:58 AM
Details	Last Recertification Date	Update	Recertification		8/23/2024 8:58:52 AM	8/23/2024 8:58 AM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Komar, Ellen CNO & Sr VP -Patient Services Stamford Health 2032767401-7401	4/19/2024 8:12 AM
Details	340B ID	Update	New Registration		DSH070006G	4/19/2024 8:12 AM
Details	Entity Subname	Update	New Registration	Diabetes & Endocrine -LRR	Diabetes & Endocrine -LRR - Diabetes Center	4/19/2024 8:12 AM
Dates	Participating Approval Date	Update	New Registration		4/19/2024 8:12:00 AM	4/19/2024 8:12 AM
Details	State	Update	New Registration	Pending	Approved	4/19/2024 8:12 AM
Dates	Signed By Date	Update	New Registration		4/11/2024 2:35:50 PM	4/19/2024 8:12 AM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	4/19/2024 8:12 AM
Addresses	Main Address	Insert	New Registration		292 Long Ridge Road Suite 206 Stamford, CT 06902-1627	4/8/2024 12:57 PM
Addresses	Billing Address	Insert	New Registration		The Stamford Hospital 1 Hospital Plaza Stamford, CT 06902	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004024964	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		350587	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		5459109	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		14095300	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MD	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		110026981B	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0937185-00	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1356331425	4/8/2024 12:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NC	4/8/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1356331425	4/8/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/8/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1356331425	4/8/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/8/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1356331425	4/8/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	4/8/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1356331425	4/8/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		MD	4/8/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1356331425	4/8/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	4/8/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1356331425	4/8/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	4/8/2024 12:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1356331425	4/8/2024 12:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	4/8/2024 12:57 PM
Contacts	Primary Contact	Insert	New Registration		Manirakiza, Prudence Pharmacy Business Manager Stamford Hospital 2032764232-4232	4/8/2024 12:57 PM
Contacts	Authorizing Official	Insert	New Registration		Komar, Ellen CNO & Sr VP -Patient Services Stamford Health 2032767401-7401	4/8/2024 12:57 PM
Details	Assistance Received From Date	Insert	New Registration			4/8/2024 12:57 PM
Details	Assistance Received To Date	Insert	New Registration			4/8/2024 12:57 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2024 12:57 PM
Details	Grant Number	Insert	New Registration			4/8/2024 12:57 PM
Details	340B ID	Insert	New Registration			4/8/2024 12:57 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2024 12:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2024 12:57 PM
Details	Medicare Provider Number	Insert	New Registration		070006	4/8/2024 12:57 PM
Details	Entity Name	Insert	New Registration		THE STAMFORD HOSPITAL	4/8/2024 12:57 PM
Details	NOFO Number	Insert	New Registration			4/8/2024 12:57 PM
Details	Program Code	Insert	New Registration		DSH	4/8/2024 12:57 PM
Details	Entity Subname	Insert	New Registration		Diabetes & Endocrine -LRR	4/8/2024 12:57 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2024 12:57 PM
Details	State	Insert	New Registration		Pending	4/8/2024 12:57 PM
Dates	Registration Date	Insert	New Registration		4/8/2024 12:57:21 PM	4/8/2024 12:57 PM
Dates	Signed By Date	Insert	New Registration			4/8/2024 12:57 PM
Dates	Start Date	Insert	New Registration			4/8/2024 12:57 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2024 12:57 PM
Terminations	Termination Date	Insert	New Registration			4/8/2024 12:57 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2024 12:57 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2024 12:57 PM