Covered Entity Details

DSH310001P HACKENSACK UNIVERSITY MEDICAL CENTER (Approved) - information as of 4/29/2025 12:33:02 AM

Main Details

Name

HACKENSACK UNIVERSITY MEDICAL CENTER

Subdivision Name

HUMC Fitness & Wellness Center - Molly Diabetes

Type

Disproportionate Share Hospital

Rural

340B ID

DSH310001P

Medicare Provider Number

310001

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/1/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/8/2025

Last Recertification Date

Contacts

Authorizing Official

Hackensack Meridian Health
William James Carroll, VP, Chief Pharmacy Officer
(562) 233-6360

Primary Contact

Hackensack Meridian Health
Sheba Saggu, 340B Program Manager
(732) 324-4909

Addresses

Street Address

87 Route 17 North
1-200
Maywood, NJ 07607

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
NJ	3674100	1457456279

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
DSH310001A	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	INSTITUTE FOR BREAST CARE - HMN MPX BREAST IMAGING	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001B	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HMN MPX MRI IMAGING - MRI	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001C	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HUMCCP MEDICAL PLAZA - HUMC CARDIO-VASCULAR	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001D	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	John Theurer Cancer Center at HUMC - JTCC Second Floor	92 2nd St	Hackensack	NJ	Approved
DSH310001E	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	John Theurer Cancer Center at HUMC - JTCC Radiation Oncology	92 2nd St	Hackensack	NJ	Approved
DSH310001F	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	John Theurer Cancer Center at HUMC - JTCC Infusion	92 2nd Street	Hackensack	NJ	Approved
DSH310001G	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HMN MPX PET IMAGING - PET/CT	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001H	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HMN MPX XR IMAGING - RADIOLOGY	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001J	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	John Theurer Cancer Center at HUMC - JTCC Blood & Marrow Transplant	92 2nd Street	Hackensack	NJ	Approved
DSH310001K	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HMN MPX US IMAGING - ULTRA SOUND	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001L	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	John Theurer Cancer Center at HUMC - JTCC Fourth Floor	92 2nd Street	Hackensack	NJ	Approved
DSH310001M	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	John Theurer Cancer Center at HUMC - JTCC Third Floor	92 2nd St	Hackensack	NJ	Approved
DSH310001N	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	CARDIAC REHABILITATION - HUMC CARDIAC REHAB	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001P	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HUMC Fitness & Wellness Center - Molly Diabetes	87 Route 17 North	Maywood	NJ	Approved
DSH310001Q	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	ALLERGY CENTER - ALLERGY CENTER	360 Essex Street	Hackensack	NJ	Approved
DSH310001R	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	John Theurer Cancer Center at HUMC - JTCC Cell Therapy	40 Prospect Avenue	Hackensack	NJ	Approved
DSH310001S	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HUMC LABORATORY - HUMC - ALL OTHER LAB	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001T	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	AUDREY HEPBURN CHILDREN'S HOUSE - Other Clinic's	12 Second Street	Hackensack	NJ	Approved
DSH310001U	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	Infusion Center - Infusion Center	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001V	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HMN CAS PERIOP - CENTER FOR AMBULATORY SURGERY	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001W	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HMN CAS PERIOP - D.A.R. - SURGICAL	20 Prospect Avenue	Hackensack	NJ	Approved
DSH310001X	Child	DSH	HACKENSACK UNIVERSITY MEDICAL CENTER	HUMC WOUND CARE - WOUND CENTER	20 Prospect Avenue	Hackensack	NJ	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Saggu, Sheba 340 Program Administrator Hackensack Meridian Health 7323244909	Saggu, Sheba 340B Program Manager Hackensack Meridian Health 7323244909	4/14/2025 9:52 AM
Contacts	Signed By	Insert	New Registration		Carroll, William James VP, Chief Pharmacy Officer Hackensack Meridian Health 5622336360	4/8/2025 8:46 AM
Details	340B ID	Update	New Registration		DSH310001P	4/8/2025 8:46 AM
Details	Entity Subname	Update	New Registration	HUMC Fitness & Wellness Center	HUMC Fitness & Wellness Center - Molly Diabetes	4/8/2025 8:46 AM
Dates	Participating Approval Date	Update	New Registration		4/8/2025 8:46:28 AM	4/8/2025 8:46 AM
Details	State	Update	New Registration	Pending	Approved	4/8/2025 8:46 AM
Dates	Signed By Date	Update	New Registration		4/7/2025 5:05:56 PM	4/8/2025 8:46 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/8/2025 8:46 AM
Addresses	Main Address	Insert	New Registration		87 Route 17 North 1-200 Maywood, NJ 07607	4/1/2025 9:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2025 9:43 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3674100	4/1/2025 9:43 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		NJ	4/1/2025 9:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1457456279	4/1/2025 9:43 AM
Medicaid Billing	NPI: State	Insert	New Registration		NJ	4/1/2025 9:43 AM
Contacts	Primary Contact	Insert	New Registration		Saggu, Sheba 340 Program Administrator Hackensack Meridian Health 7323244909	4/1/2025 9:43 AM
Contacts	Authorizing Official	Insert	New Registration		Carroll, William James VP, Chief Pharmacy Officer Hackensack Meridian Health 5622336360	4/1/2025 9:43 AM
Details	Assistance Received From Date	Insert	New Registration			4/1/2025 9:43 AM
Details	Assistance Received To Date	Insert	New Registration			4/1/2025 9:43 AM
Details	Last Recertification Date	Insert	New Registration			4/1/2025 9:43 AM
Details	Grant Number	Insert	New Registration			4/1/2025 9:43 AM
Details	340B ID	Insert	New Registration			4/1/2025 9:43 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2025 9:43 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2025 9:43 AM
Details	Medicare Provider Number	Insert	New Registration		310001	4/1/2025 9:43 AM
Details	Entity Name	Insert	New Registration		HACKENSACK UNIVERSITY MEDICAL CENTER	4/1/2025 9:43 AM
Details	NOFO Number	Insert	New Registration			4/1/2025 9:43 AM
Details	Program Code	Insert	New Registration		DSH	4/1/2025 9:43 AM
Details	Entity Subname	Insert	New Registration		HUMC Fitness & Wellness Center	4/1/2025 9:43 AM
Dates	Participating Approval Date	Insert	New Registration			4/1/2025 9:43 AM
Details	State	Insert	New Registration		Pending	4/1/2025 9:43 AM
Dates	Registration Date	Insert	New Registration		4/1/2025 9:43:26 AM	4/1/2025 9:43 AM
Dates	Signed By Date	Insert	New Registration			4/1/2025 9:43 AM
Dates	Start Date	Insert	New Registration			4/1/2025 9:43 AM
Terminations	Termination Comments	Insert	New Registration			4/1/2025 9:43 AM
Terminations	Termination Date	Insert	New Registration			4/1/2025 9:43 AM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2025 9:43 AM
Terminations	Termination Reason	Insert	New Registration			4/1/2025 9:43 AM