Covered Entity Details

DSH070031G THE GRIFFIN HOSPITAL (Active) - information as of 5/29/2025 1:49:48 AM

Main Details

Name

THE GRIFFIN HOSPITAL

Subdivision Name

Griffin Hospital Occupational Medicine Department - Occupation and Employee Health

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070031G

Medicare Provider Number

070031

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/9/2024

Participating Start Date

7/1/2024

Participating Approval Date

4/19/2024

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Griffin Hospital
Alexander Stephen Balko, VP Finance/CFO
(203) 732-7594

Primary Contact

Griffin Hospital
Lisa Jean Jaser, Director of Pharmacy
(203) 732-7311

Addresses

Street Address

10 Progress Drive
Shelton, CT 06484

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?
Yes

State	Medicaid Number	NPI Number
CT	004025219,004041927	1184639973

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
DSH070031A	Child	DSH	THE GRIFFIN HOSPITAL	GRIFFIN CENTER FOR CANCER CARE - Cancer Center Infusion Center	350 SEYMOUR AVE	DERBY	CT	Active
DSH070031B	Child	DSH	THE GRIFFIN HOSPITAL	GRIFFIN CENTER FOR CANCER CARE - Radiation Oncology Site	350 SEYMOUR AVE	DERBY	CT	Active
DSH070031C	Child	DSH	THE GRIFFIN HOSPITAL	GRIFFIN CENTER FOR CANCER CARE - Mammography - Breast Wellness Center	350 SEYMOUR AVE	DERBY	CT	Active
DSH070031D	Child	DSH	THE GRIFFIN HOSPITAL	OP Psych Clinic - Outpatient Psychatric Clinic	248 & 250 Seymour Ave	Derby	CT	Active
DSH070031E	Child	DSH	THE GRIFFIN HOSPITAL	GRIFFIN IMAGING & DIAGNOSTIC CENTER - CatScan Ivy Brook	2 IVY BROOK RD	SHELTON	CT	Active
DSH070031F	Child	DSH	THE GRIFFIN HOSPITAL	OP Psych Clinic - Shelton - Outpatient Psychatric Clinic - Shelton	10 Progress Drive	Shelton	CT	Active
DSH070031G	Child	DSH	THE GRIFFIN HOSPITAL	Griffin Hospital Occupational Medicine Department - Occupation and Employee Health	10 Progress Drive	Shelton	CT	Active
DSH070031H	Child	DSH	THE GRIFFIN HOSPITAL	Commerce Drive X-Ray Services - X-Ray Services	110 Progressive Drive	Shelton	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/15/2024 1:12:34 PM	8/15/2024 1:12 PM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Balko, Alexander Stephen VP Finance/CFO Griffin Hospital 2037327594	4/19/2024 8:58 AM
Details	340B ID	Update	New Registration		DSH070031G	4/19/2024 8:58 AM
Details	Entity Subname	Update	New Registration	Griffin Hospital Occupational Medicine Department	Griffin Hospital Occupational Medicine Department - Occupation and Employee Health	4/19/2024 8:58 AM
Dates	Participating Approval Date	Update	New Registration		4/19/2024 8:58:43 AM	4/19/2024 8:58 AM
Details	State	Update	New Registration	Pending	Approved	4/19/2024 8:58 AM
Dates	Signed By Date	Update	New Registration		4/9/2024 1:58:00 PM	4/19/2024 8:58 AM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	4/19/2024 8:58 AM
Addresses	Main Address	Insert	New Registration		10 Progress Drive Shelton, CT 06484	4/9/2024 1:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/9/2024 1:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004025219	4/9/2024 1:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/9/2024 1:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/9/2024 1:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004041927	4/9/2024 1:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/9/2024 1:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1184639973	4/9/2024 1:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/9/2024 1:57 PM
Contacts	Authorizing Official	Insert	New Registration		Balko, Alexander Stephen VP Finance/CFO Griffin Hospital 2037327594	4/9/2024 1:57 PM
Contacts	Primary Contact	Insert	New Registration		Jaser, Lisa Jean Director of Pharmacy Griffin Hospital 2037327311	4/9/2024 1:57 PM
Details	Assistance Received From Date	Insert	New Registration			4/9/2024 1:57 PM
Details	Assistance Received To Date	Insert	New Registration			4/9/2024 1:57 PM
Details	Last Recertification Date	Insert	New Registration			4/9/2024 1:57 PM
Details	Grant Number	Insert	New Registration			4/9/2024 1:57 PM
Details	340B ID	Insert	New Registration			4/9/2024 1:57 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/9/2024 1:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/9/2024 1:57 PM
Details	Medicare Provider Number	Insert	New Registration		070031	4/9/2024 1:57 PM
Details	Entity Name	Insert	New Registration		THE GRIFFIN HOSPITAL	4/9/2024 1:57 PM
Details	NOFO Number	Insert	New Registration			4/9/2024 1:57 PM
Details	Program Code	Insert	New Registration		DSH	4/9/2024 1:57 PM
Details	Entity Subname	Insert	New Registration		Griffin Hospital Occupational Medicine Department	4/9/2024 1:57 PM
Dates	Participating Approval Date	Insert	New Registration			4/9/2024 1:57 PM
Details	State	Insert	New Registration		Pending	4/9/2024 1:57 PM
Dates	Registration Date	Insert	New Registration		4/9/2024 1:57:56 PM	4/9/2024 1:57 PM
Dates	Signed By Date	Insert	New Registration			4/9/2024 1:57 PM
Dates	Start Date	Insert	New Registration			4/9/2024 1:57 PM
Terminations	Termination Comments	Insert	New Registration			4/9/2024 1:57 PM
Terminations	Termination Date	Insert	New Registration			4/9/2024 1:57 PM
Terminations	Termination Effective Date	Insert	New Registration			4/9/2024 1:57 PM
Terminations	Termination Reason	Insert	New Registration			4/9/2024 1:57 PM