Covered Entity Details

DSH390256CB MILTON S. HERSHEY MEDICAL CENTER (Approved) - information as of 5/3/2025 11:28:05 PM

Main Details

Name

MILTON S. HERSHEY MEDICAL CENTER

Subdivision Name

Campus Drive Suite 1300- Medicine-Pulmonology General - Pulmonology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH390256CB

Medicare Provider Number

390256

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/2/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/7/2025

Last Recertification Date

Contacts

Authorizing Official

Penn State Health
Tracy L Moyer, Senior Vice President of Financial Operations
(717) 531-8477

Primary Contact

Penn State Health
Samuel Wetherill, VP Pharmacy
(410) 920-4494

Addresses

Street Address

200 Campus Dr.
1300
Hershey, PA 17033

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
PA	1007653100005	1568435477

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
DSH390256AA	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Obstetrics & Gynecology - REPRODUCTIVE ENDOCRINOLOGY	35 Hope Drive	Hershey	PA	Active
DSH390256AB	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Pediatric Bone & Joint (Spina Bifida)	30 Hope Drive	HERSHEY	PA	Terminated
DSH390256AC	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Therapy Services (Speech Therapy)	30 Hope Drive	Hershey	PA	Active
DSH390256AD	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Therapy Services (Occupational Therapy)	30 Hope Drive	Hershey	PA	Active
DSH390256AE	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Therapy Services (Physical Therapy)	30 Hope Drive	Hershey	PA	Active
DSH390256AF	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Briarcrest (Diabetes & Weight)	905 W. Governor Road	Hershey	PA	Active
DSH390256AG	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Briarcrest (Adolescent Medicine)	905 W. Governor Road	Hershey	PA	Active
DSH390256AH	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Briarcrest (Pediatric Specialties)	905 W. Governor Road	Hershey	PA	Active
DSH390256AJ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Mount Joy	201 Lefever Rd.	Mount Joy	PA	Active
DSH390256AK	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Psychiatry	22 North East Dr.	HERSHEY	PA	Active
DSH390256AL	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	PSHMG Camp Hill HVI / Heart and Vascular	3025 Market St.	Camp Hill	PA	Terminated
DSH390256AM	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	PSHMG Camp Hill / Echocardiogram	3025 Market St.	camp Hill	PA	Terminated
DSH390256AN	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Road II / Echocardiogram	121 Nyes Road	Harrisburg	PA	Terminated
DSH390256AP	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Neurophysiology	30 Hope Drive	Hershey	PA	Active
DSH390256AQ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Plastic Surgery	30 Hope Drive	Hershey	PA	Active
DSH390256AR	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Palmyra HVI / Heart and Vascular	941 Park Dr.	Palmyra	PA	Active
DSH390256AS	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Breast Imaging / Diagnostic Imaging	30 Hope Dr.	Hershey	PA	Terminated
DSH390256AT	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Penn State Hershey Medical Group Nyes Rd. / Diagnostic Imaging	121 Nyes Rd.	Harrisburg	PA	Terminated
DSH390256AU	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	"PSHMG Mechanicsburg Family Medicine"	140 Old Willow Mill Road	Mechanicsburg	PA	Active
DSH390256AV	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Cocoaplex-Medicine - Multi Specialty	1150 Cocoa Avenue	Hershey	PA	Active
DSH390256AW	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Pediatric Specialties - Pediatric specialties	200 Campus Drive	Hershey	PA	Active
DSH390256AX	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Pain Medicine - Pain management UPC	200 Campus Drive	Hershey	PA	Active
DSH390256AY	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Renal Dialysis (Hemodialysis) - Hemodialysis	200 Campus Drive	Hershey	PA	Active
DSH390256AZ	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Surgery Specialties (IBD Center) - Irritable bowel disease	200 Campus Drive	Hershey	PA	Terminated
DSH390256B	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Campe Hill Entrance B.Family Med - General	3025 Market St	Camp Hill	PA	Active
DSH390256BA	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Heart & Vascular Services - Cardiology services UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BB	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Medicine Specialties - Medicine specialties	200 Campus Drive	Hershey	PA	Terminated
DSH390256BC	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Ophthalmology - Ophthalmology	200 Campus Drive	Hershey	PA	Active
DSH390256BD	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Practice Management Clinic – Anesthesia Clinic	200 Campus Drive	Hershey	PA	Active
DSH390256BE	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Otolaryngology - Head/Neck surgical services	200 Campus Drive	Hershey	PA	Terminated
DSH390256BF	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Cancer Institute (Practice Site) - Office visits	400 University Drive	Hershey	PA	Active
DSH390256BG	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Cancer Institute (Hem/Onc & Infusion) - Hematology/Oncology and Infusion	400 University Drive	Hershey	PA	Active
DSH390256BH	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Pediatric Hem/Onc & Infusion - Hematology/Oncology and Infusion	600 University Drive	Hershey	PA	Active
DSH390256BJ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Dermatology UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BK	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	West Campus Allergy Asthma & Immunology	10 Conference Drive	Hershey	PA	Active
DSH390256BL	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Endoscopy UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BN	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Surgery Specialties UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BP	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Audiology UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BQ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Renal Dialysis (Peritineal) - Peritineal	200 Campus Drive	Hershey	PA	Active
DSH390256BR	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Medicine Suite - Medicine Specialties	200 Campus Drive	Hershey	PA	Active
DSH390256BS	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Medicine Specialties (Diabetes) - Diabetes Education	200 Campus Drive	Hershey	PA	Active
DSH390256BT	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PENN STATE HERSHEY-LIME SPRINGS - Therapy Services	2221 NOLL DRIVE	LANCASTER	PA	Active
DSH390256BU	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG - Pediatric Specialties Lancaster	1430 Harrisburg Pike	LANCASTER	PA	Active
DSH390256BV	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PENN STATE HERSHEY-LIME SPRINGS - Infusion	2221 NOLL DRIVE	LANCASTER	PA	Active
DSH390256BW	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	"PSHMG Lime Springs Specialties"	2221 NOLL DRIVE	LANCASTER	PA	Active
DSH390256BX	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PENN STATE HERSHEY-LIME SPRINGS - Audiology	2221 NOLL DRIVE	LANCASTER	PA	Active
DSH390256BY	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSMG HOPE DR 35 - Internal Medicine	35 HOPE DRIVE	HERSHEY	PA	Active
DSH390256BZ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSMG NYES ROAD - Audiology	121 NYES ROAD	HARRISBURG	PA	ToBeTerminated
DSH390256C	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Camp Hill Specialties	3025 Market St	Camp Hill	PA	Active
DSH390256CA	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSMG HOPE DR 35 - Womens Health	35 HOPE DRIVE	HERSHEY	PA	Active
DSH390256CB	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Campus Drive Suite 1300- Medicine-Pulmonology General - Pulmonology	200 Campus Dr.	Hershey	PA	Approved
DSH390256D	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Harrisburg	2626 North Third Street	Harrisburg	PA	Active
DSH390256E	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Road II	121 Nyes Road Suite F	Harrisburg	PA	Active
DSH390256F	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Rd Pediatric Cardiology	121 Nyes Road Suite D	Harrisburg	PA	Active
DSH390256G	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Road I	121 Nyes Road Suite A	Harrisburg	PA	Active
DSH390256H	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Fishburn Road	845 Fishburn Rd	Hershey	PA	Active
DSH390256J	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Road Specialties	121 Nyes Rd Suite C	Harrisburg	PA	Active
DSH390256K	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Middletown	3100 Schoolhouse Rd	Middletown	PA	Active
DSH390256L	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Rd Heart & Vascular	121 Nyes Road Suite E	Harrisburg	PA	Active
DSH390256M	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Elizabethtown	1 Continental Dr	Elizabethtown	PA	Active
DSH390256N	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Middletown Surgery Specialties	3100 Schoolhouse Rd	Middletown	PA	Active
DSH390256P	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Palmyra	941 Park Dr	Palmyra	PA	Active
DSH390256Q	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	PSHCH - Lancaster Outpatient	2170 Noll Dr	Lancaster	PA	Terminated
DSH390256R	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Physical Medicine Rehab	1135 Old West Chocolate Avenue	Hummelstown	PA	Active
DSH390256S	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Neurosurgery Clinic	30 Hope Drive	Hershey	PA	Active
DSH390256T	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Breast Center	30 Hope Drive	Hershey	PA	Active
DSH390256U	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Orthopedics Clinic	30 Hope Drive	Hershey	PA	Active
DSH390256V	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Pediatric Bone & Joint	30 Hope Drive	Hershey	PA	Active
DSH390256W	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Cosmetic Surgery	5 Capital Drive	Harrisburg	PA	Terminated
DSH390256X	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Penn State Hershey Internal Medicine	35 Hope Drive	Hershey	PA	Terminated
DSH390256Y	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Neurology Clinic	30 Hope Drive	Hershey	PA	Active
DSH390256Z	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Penn State Hershey Pediatrics	35 Hope Drive	Hershey	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Moyer, Tracy L Senior Vice President of Financial Operations Penn State Health 7175318477	4/7/2025 9:37 AM
Details	340B ID	Update	New Registration		DSH390256CB	4/7/2025 9:37 AM
Details	Entity Subname	Update	New Registration	Campus Drive Suite 1300- Medicine-Pulmonology General	Campus Drive Suite 1300- Medicine-Pulmonology General - Pulmonology	4/7/2025 9:37 AM
Dates	Participating Approval Date	Update	New Registration		4/7/2025 9:37:30 AM	4/7/2025 9:37 AM
Details	State	Update	New Registration	Pending	Approved	4/7/2025 9:37 AM
Dates	Signed By Date	Update	New Registration		4/3/2025 6:54:07 AM	4/7/2025 9:37 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/7/2025 9:37 AM
Addresses	Main Address	Insert	New Registration		200 Campus Dr. 1300 Hershey, PA 17033	4/2/2025 9:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/2/2025 9:05 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007653100005	4/2/2025 9:05 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/2/2025 9:05 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1568435477	4/2/2025 9:05 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/2/2025 9:05 AM
Contacts	Primary Contact	Insert	New Registration		Wetherill, Samuel VP Pharmacy Penn State Health 4109204494	4/2/2025 9:05 AM
Contacts	Authorizing Official	Insert	New Registration		Moyer, Tracy L Senior Vice President of Financial Operations Penn State Health 7175318477	4/2/2025 9:05 AM
Details	Assistance Received From Date	Insert	New Registration			4/2/2025 9:05 AM
Details	Assistance Received To Date	Insert	New Registration			4/2/2025 9:05 AM
Details	Last Recertification Date	Insert	New Registration			4/2/2025 9:05 AM
Details	Grant Number	Insert	New Registration			4/2/2025 9:05 AM
Details	340B ID	Insert	New Registration			4/2/2025 9:05 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/2/2025 9:05 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/2/2025 9:05 AM
Details	Medicare Provider Number	Insert	New Registration		390256	4/2/2025 9:05 AM
Details	Entity Name	Insert	New Registration		MILTON S. HERSHEY MEDICAL CENTER	4/2/2025 9:05 AM
Details	NOFO Number	Insert	New Registration			4/2/2025 9:05 AM
Details	Program Code	Insert	New Registration		DSH	4/2/2025 9:05 AM
Details	Entity Subname	Insert	New Registration		Campus Drive Suite 1300- Medicine-Pulmonology General	4/2/2025 9:05 AM
Dates	Participating Approval Date	Insert	New Registration			4/2/2025 9:05 AM
Details	State	Insert	New Registration		Pending	4/2/2025 9:05 AM
Dates	Registration Date	Insert	New Registration		4/2/2025 9:05:03 AM	4/2/2025 9:05 AM
Dates	Signed By Date	Insert	New Registration			4/2/2025 9:05 AM
Dates	Start Date	Insert	New Registration			4/2/2025 9:05 AM
Terminations	Termination Comments	Insert	New Registration			4/2/2025 9:05 AM
Terminations	Termination Date	Insert	New Registration			4/2/2025 9:05 AM
Terminations	Termination Effective Date	Insert	New Registration			4/2/2025 9:05 AM
Terminations	Termination Reason	Insert	New Registration			4/2/2025 9:05 AM