Covered Entity Details

RRC330011-45 OUR LADY OF LOURDES MEMORIAL HOSP (Active) - information as of 6/26/2025 12:18:29 AM

Main Details

Name

OUR LADY OF LOURDES MEMORIAL HOSP

Subdivision Name

LOURDES ENT - ENT

Type

Rural Referral Center

Rural

Yes

340B ID

RRC330011-45

Medicare Provider Number

330011

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2024

Participating Start Date

7/1/2024

Participating Approval Date

5/14/2024

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Guthrie Lourdes Hospital
Kathryn Connerton, President
(607) 798-5328

Primary Contact

Guthrie Lourdes Hospital
Paul Mollo, Sr. VP, Chief Pharmacy Officer
(607) 727-5577

Addresses

Street Address

161 RIVERSIDE DR
STE M10
BINGHAMTON, NY 13905-4112

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
NY	00337664	1629087580

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
RRC330011-01	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Vestal Family Practice	3101 Shippers Road	VESTAL	NY	Active
RRC330011-02	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Broome Urology Associates at Lourdes	169 Riverside Dr	Binghamton	NY	Active
RRC330011-03	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Primary Care - 303 Main	303 MAIN STREET	BINGHAMTON	NY	Terminated
RRC330011-04	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Lourdes Breast Care Center	169 Riverside Dr	Binghamton	NY	Active
RRC330011-05	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES CENTER FOR FAMILY HEALTH	ROUTE 38	RICHFORD	NY	Terminated
RRC330011-06	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES FAMILY PRACTICE	7320 ACADEMY ST	WHITNEY POINT	NY	Terminated
RRC330011-07	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Hancock Family Practice	39E MAIN ST	HANCOCK	NY	Active
RRC330011-08	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Owego Family Practice	500 5TH AVENUE	OWEGO	NY	Active
RRC330011-09	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES FAMILY PRACTICE UPPER FRON	1130 UPPER FRONT STREET	BINGHAMTON	NY	Terminated
RRC330011-10	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Lourdes Gastroenterology	161 Riverside Dr	Binghamton	NY	Active
RRC330011-11	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES PEDIATRICS	161 RIVERSIDE DRIVE	BINGHAMTON	NY	Terminated
RRC330011-12	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES LAB SERVICES	26S WASHINGTON ST	BINGHAMTON	NY	Terminated
RRC330011-13	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Lourdes Palliative Care	169 Riverside Drive	Binghamton	NY	Active
RRC330011-14	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	WOMEN'S HEALTH SERVICES	3101 SHIPPERS RD	VESTAL	NY	Active
RRC330011-15	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Endicott Walk In	415 EAST MAIN STREET	ENDICOTT	NY	Active
RRC330011-16	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	PRIMARY CARE ASSOCIATES - WHITNEY P	7320 ACADEMY STREET	WHITNEY POINT	NY	Terminated
RRC330011-17	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	PCA Eastside	276-280 ROBINSON STREET	BINGHAMTON	NY	Active
RRC330011-18	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	RIVERSIDE MEDICAL	161 RIVERSIDE DRIVE	BINGHAMTON	NY	Active
RRC330011-19	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Lourdes Endocrinology	169 Riverside Dr	Binghamton	NY	Terminated
RRC330011-20	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Vestal Family Practice	105 RIDGEHAVEN DR	VESTAL	NY	Terminated
RRC330011-21	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Upper Front Street Practice	17 Chenango Bridge Road	BINGHAMTON	NY	Active
RRC330011-22	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	North Tioga Center for Family Health	13293 STATE RTE 38	RICHFORD	NY	Terminated
RRC330011-23	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Owego Walk In	500 5TH AVE	OWEGO	NY	Active
RRC330011-24	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Pediatric Center	161 RIVERSIDE DR 206	BINGHAMTON	NY	Active
RRC330011-25	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	PCA Endicott	415 E MAIN ST	ENDICOTT	NY	Active
RRC330011-26	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES CENTER FOR ORAL HEALTH	219 FRONT STREET	BINGHAMTON	NY	Active
RRC330011-27	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Whitney Point Practice	2660 MAIN ST	WHITNEY POINT	NY	Active
RRC330011-28	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	DePaul Children's Clinic	303 MAIN ST	BINGHAMTON	NY	Terminated
RRC330011-29	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Eastside Walk In	276-280 ROBINSON ST	BINGHAMTON	NY	Active
RRC330011-30	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Vestal Internal Medicine	3101 SHIPPERS RD 202	VESTAL	NY	Active
RRC330011-31	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES DERMATOLOGY	415 E Main St	Endicott	NY	Active
RRC330011-32	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES VASCULAR SURGERY	161 RIVERSIDE DR	BINGHAMTON	NY	Active
RRC330011-33	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	GERIATRIC CARE	169 Riverside Drive	binghamton	NY	Terminated
RRC330011-34	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Lourdes Pulmonary Services	169 Riverside Dr	Binghamton	NY	Terminated
RRC330011-35	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	DeMarrilac Clinic	303 Main Street	Binghamton	NY	Terminated
RRC330011-36	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Vestal Walk-in	3101 SHIPPERS RD	Vestal	NY	Active
RRC330011-37	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Mental Health	184 Court Street	Binghamton	NY	Active
RRC330011-38	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Sleep Lab	116 N. Jensen Road	Vestal	NY	Active
RRC330011-39	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Vestal / Occupational Health	3101 Shippers Road	Vestal	NY	Terminated
RRC330011-40	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	Lourdes Orthopedics - Orthopedics	240 Riverside Drive	Johnson City	NY	Active
RRC330011-41	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES PAIN & WELLNESS - Pain & Wellness	20-24 S WASHINGTON ST	BINGHAMTON	NY	Active
RRC330011-42	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	OUR LADY OF LOURDES MEMORIAL - Pediatrics	105 RIDGEHAVEN DR	VESTAL	NY	Terminated
RRC330011-43	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES ORTHOPEDICS SOUTHSIDE - orthopedics	65 PENNSYLVANIA AVE	BINGHAMTON	NY	Active
RRC330011-44	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES ENDOCRINOLOGY - Endocrinology	161 RIVERSIDE DR	BINGHAMTON	NY	Active
RRC330011-45	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES ENT - ENT	161 RIVERSIDE DR	BINGHAMTON	NY	Active
RRC330011-46	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES MICRO SURGERY - Micro Surgery	65 PENNSYLVANIA AVE	BINGHAMTON	NY	Active
RRC330011-47	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	RIVERSIDE SURGERY - Surgery	169 RIVERSIDE DR	BINGHAMTON	NY	Active
RRC330011-48	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	OUR LADY OF LOURDES MEMORIAL HOSPIT - Geriatric Care	27 JENNISON AVE	JOHNSON CITY	NY	Active
RRC330011-49	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES RHEUMATOLOGY - RHEUMATOLOGY	161 RIVERSIDE DR	BINGHAMTON	NY	Active
RRC330011-50	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	OUR LADY OF LOURDES MEMORIAL HOSPIT - Primary Care	12 SCHOOL ST	NEW BERLIN	NY	Active
RRC330011-51	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES PULMONOLOGY - PULMONOLOGY	161 RIVERSIDE DR M05	BINGHAMTON	NY	Active
RRC330011-52	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	CARDIOLOGYM07 - Cardiology	161 RIVERSIDE DR	BINGHAMTON	NY	Active
RRC330011-53	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES PLASTIC SURGERY - Plastic Surgery	161 RIVERSIDE DR	BINGHAMTON	NY	Active
RRC330011-54	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	OUR LADY OF LOURDES MEMORIAL HOSPIT - PODIATRY	501 Reynolds Rd	Johnson City	NY	Active
RRC330011-55	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	OUR LADY OF LOURDES MEMORIAL HOSPIT - Weight Loss/Cardiometabolic Clinic	501 Reynolds Rd	Johnson City	NY	Active
RRC330011-56	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	PRIMARY CARE - JOHNSON CITY - Primary Care	501 REYNOLDS RD.	JOHNSON CITY	NY	Active
RRC330011-57	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES SPECIALTY CARE - Specialty Care	501 REYNOLDS RD.	JOHNSON CITY	NY	Active
RRC330011-58	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	OUR LADY OF LOURDES MEMORIAL HOSPIT - Chenango Bridge Walk-In	17 CHENANGO BRIDGE RD	BINGHAMTON	NY	Active
RRC330011-59	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	LOURDES PODIATRY - Podiatry	161 RIVERSIDE DR	BINGHAMTON	NY	Active
RRC330011-60	Child	RRC	OUR LADY OF LOURDES MEMORIAL HOSP	OUR LADY OF LOURDES MEMORIAL HOSPIT - Wound Care	3101 SHIPPERS RD	VESTAL	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Caito, Bridget 340b Program Manager Ascension Rx 2485638931	Mollo, Paul Sr. VP, Chief Pharmacy Officer Guthrie Lourdes Hospital 6077275577	1/27/2025 7:43 AM
Contacts	Authorizing Official	Update	Change Request	Connerton, Kathryn CEO Our Lady of Lourdes Memorial Hospital, Inc. 6077985328	Connerton, Kathryn President Guthrie Lourdes Hospital 6077985328	1/15/2025 11:05 AM
Details	Last Recertification Date	Update	Recertification		8/14/2024 2:16:17 PM	8/14/2024 2:16 PM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Connerton, Kathryn CEO Our Lady of Lourdes Memorial Hospital, Inc. 6077985328	5/14/2024 8:44 AM
Details	340B ID	Update	New Registration		RRC330011-45	5/14/2024 8:44 AM
Details	Entity Subname	Update	New Registration	LOURDES ENT	LOURDES ENT - ENT	5/14/2024 8:44 AM
Dates	Participating Approval Date	Update	New Registration		5/14/2024 8:44:19 AM	5/14/2024 8:44 AM
Details	State	Update	New Registration	Pending	Approved	5/14/2024 8:44 AM
Dates	Signed By Date	Update	New Registration		5/6/2024 3:51:21 PM	5/14/2024 8:44 AM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	5/14/2024 8:44 AM
Addresses	Main Address	Insert	New Registration		161 RIVERSIDE DR STE M10 BINGHAMTON, NY 13905-4112	4/15/2024 12:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2024 12:56 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00337664	4/15/2024 12:56 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/15/2024 12:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629087580	4/15/2024 12:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/15/2024 12:56 PM
Contacts	Authorizing Official	Insert	New Registration		Connerton, Kathryn CEO Our Lady of Lourdes Memorial Hospital, Inc. 6077985328	4/15/2024 12:56 PM
Contacts	Primary Contact	Insert	New Registration		Caito, Bridget 340b Program Manager Ascension Rx 2485638931	4/15/2024 12:56 PM
Details	Assistance Received From Date	Insert	New Registration			4/15/2024 12:56 PM
Details	Assistance Received To Date	Insert	New Registration			4/15/2024 12:56 PM
Details	Last Recertification Date	Insert	New Registration			4/15/2024 12:56 PM
Details	Grant Number	Insert	New Registration			4/15/2024 12:56 PM
Details	340B ID	Insert	New Registration			4/15/2024 12:56 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/15/2024 12:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/15/2024 12:56 PM
Details	Medicare Provider Number	Insert	New Registration		330011	4/15/2024 12:56 PM
Details	Entity Name	Insert	New Registration		OUR LADY OF LOURDES MEMORIAL HOSP	4/15/2024 12:56 PM
Details	NOFO Number	Insert	New Registration			4/15/2024 12:56 PM
Details	Program Code	Insert	New Registration		RRC	4/15/2024 12:56 PM
Details	Entity Subname	Insert	New Registration		LOURDES ENT	4/15/2024 12:56 PM
Dates	Participating Approval Date	Insert	New Registration			4/15/2024 12:56 PM
Details	State	Insert	New Registration		Pending	4/15/2024 12:56 PM
Dates	Registration Date	Insert	New Registration		4/15/2024 12:56:25 PM	4/15/2024 12:56 PM
Dates	Signed By Date	Insert	New Registration			4/15/2024 12:56 PM
Dates	Start Date	Insert	New Registration			4/15/2024 12:56 PM
Terminations	Termination Comments	Insert	New Registration			4/15/2024 12:56 PM
Terminations	Termination Date	Insert	New Registration			4/15/2024 12:56 PM
Terminations	Termination Effective Date	Insert	New Registration			4/15/2024 12:56 PM
Terminations	Termination Reason	Insert	New Registration			4/15/2024 12:56 PM