Covered Entity Details

DSH210013 Grace Medical Center, Inc. (Terminated) - information as of 6/2/2025 8:30:36 AM

Main Details

Name

Grace Medical Center, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH210013

Medicare Provider Number

210013

Additional Details

Current Program Status

Terminated

Registration Date

5/19/2008

Participating Start Date

10/1/2002

Participating Approval Date

5/19/2008

Last Recertification Date

9/10/2021

Termination Date
Termination Reason

4/1/2022
Change of covered entity type (non-hospital)

Contacts

Authorizing Official

LifeBridge Health
Rebecca Altman, Vice President and Chief Integration Officer
(410) 601-9000

Primary Contact

Sinai Hospital
Lisa Polinsky, AVP, Pharmacy Services
(410) 601-4274

Addresses

Street Address

2000 WEST BALTIMORE STREET
BALTIMORE, MD 21223

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
MD	000175900	1962480772

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	CORRECT RX PHARMACY SERVICES	1352 CHARWOOD ROAD	SUITE C	HANOVER	MD	21076	01/15/2014	04/01/2014	10/15/2018	10/15/2018
Contract Detail	GOOD HEALTH PHARMACY AT HANOVER	8200 MEADOWBRIDGE RD STE 301		MECHANICSVILLE	VA	23116-2337	12/10/2017	01/01/2018	10/07/2019	10/07/2019
Contract Detail	HARNESS HEALTH PHARMACY	7160 INDUSTRIAL ROW DR	SUITE 330	MASON	OH	45040	01/18/2019	04/01/2019	10/07/2019	10/07/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #16188	2000 W. BALTIMORE STREET	BALTIMORE	MD	21223	05/08/2014	05/08/2014	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05408	1300 EAST NORTH AVE	BALTIMORE	MD	21213-1406	07/03/2014	10/01/2014	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #16191	2411 W. BELVEDERE AVENUE SUITE 101	BALTIMORE	MD	21215	01/11/2022	04/01/2022	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05623	3801 LIBERTY HEIGHTS AVE	BALTIMORE	MD	21215	01/11/2022	04/01/2022	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05331	8050 LIBERTY ROAD	BALTIMORE	MD	21244	01/11/2022	04/01/2022	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #16190	301 SAINT PAUL ST	BALTIMORE	MD	21202	01/11/2022	04/01/2022	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07574	5657 BALTIMORE NATIONAL PIKE	CATONSVILLE	MD	21228-1412	01/11/2022	04/01/2022	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #17522	238 MCMECHEN ST	BALTIMORE	MD	21217	01/11/2022	04/01/2022	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #17609	300 MARTIN LUTHER KING JR BLVD	BALTIMORE	MD	21201	01/11/2022	04/01/2022	04/01/2022	04/01/2022
Contract Detail	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	07/03/2014	10/01/2014	07/08/2015	08/25/2015
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/03/2014	10/01/2014	07/08/2015	08/25/2015

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH210013A	Child	DSH	Grace Medical Center, Inc.	St. Francis Outpatient Center	10 North Payson Street	Baltimore	MD	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/28/2022 12:00:00 AM	2/25/2022 9:25 AM
Details	State	Update	Termination Request	Active	To Be Terminated	2/25/2022 9:25 AM
Terminations	Termination Date	Update	Termination Request		4/1/2022 12:00:00 AM	2/25/2022 9:25 AM
Terminations	Termination Effective Date	Update	Termination Request		3/1/2022 12:00:00 AM	2/25/2022 9:25 AM
Terminations	Termination Reason	Update	Termination Request		Change of covered entity type (non-hospital)	2/25/2022 9:25 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 12:11:26 PM	9/10/2021 9:04:58 AM	9/10/2021 9:04 AM
Medicaid Billing	NPI: State	Update	Recertification		MD	8/20/2020 12:11 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 11:41:47 AM	8/20/2020 12:11:26 PM	8/20/2020 12:11 PM
Details	Entity Name	Update	Change Request	BON SECOURS HOSPITAL BALTIMORE, INC.	Grace Medical Center, Inc.	6/23/2020 10:51 AM
Contacts	Primary Contact	Update	Change Request	Deal, Coley W 340B Program Manager Bon Secours 8042214837	Polinsky, Lisa AVP, Pharmacy Services Sinai Hospital 4106014274	12/19/2019 9:25 AM
Contacts	Authorizing Official	Update	Change Request	Brozic, Michael A CFO Bon Secours Baltimore Bon Secours Mery Health 4109131546	Altman, Rebecca Vice President and Chief Integration Officer LifeBridge Health 4106019000	12/19/2019 9:25 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 12:38:17 PM	9/5/2019 11:41:47 AM	9/5/2019 11:41 AM
Contacts	Authorizing Official	Update	Change Request	Bartlett, Cindy K. VP Corporate Responsibility Bon Secours Health System 7576735835	Brozic, Michael A CFO Bon Secours Baltimore Bon Secours Mery Health 4109131546	12/7/2018 11:53 AM
Details	Last Recertification Date	Update	Recertification	11/29/2017 3:38:43 PM	8/22/2018 12:38:17 PM	8/22/2018 12:38 PM
Contacts	Primary Contact	Update	Change Request	Robinson, Norbert Director of Pharmacy Bon Secours Hospital Baltimore 4103623245	Deal, Coley W 340B Program Manager Bon Secours 8042214837	8/8/2018 12:15 PM
Contacts	Authorizing Official	Update	AO Change Request	Buck, Shelly COO/CNO Bon Secours Baltimore 4103623618	Bartlett, Cindy K. VP Corporate Responsibility Bon Secours Health System 7576735835	3/26/2018 9:16 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1962480772	11/29/2017 3:38 PM
Details	Last Recertification Date	Update	Recertification	8/12/2016 12:00:00 AM	11/29/2017 3:38:43 PM	11/29/2017 3:38 PM
Contacts	Primary Contact	Update		Robinson, Norbert Director of Pharmacy 4103623245	Robinson, Norbert Director of Pharmacy Bon Secours Hospital Baltimore 4103623245	10/3/2017 11:36 AM
Contacts	Authorizing Official	Update		Buck, Shelly COO/CNO 4103623618	Buck, Shelly COO/CNO Bon Secours Baltimore 4103623618	10/3/2017 11:28 AM
Addresses	Main Address	Insert			2000 WEST BALTIMORE STREET BALTIMORE, MD 21223	10/22/2016 9:39 AM
Contacts	Primary Contact	Update		Dimarucot, Imee 340 B Coordinator 4103623678	Robinson, Norbert Director of Pharmacy 4103623245	10/22/2016 9:39 AM
Contacts	Authorizing Official	Update		JONES, RICHARD CFO 4103623716	Buck, Shelly COO/CNO 4103623618	10/22/2016 9:39 AM
Contacts	Primary Contact	Update		Alabi, Esther Director of Pharmacy 4103623245	Dimarucot, Imee 340 B Coordinator 4103623678	8/12/2016 11:09 AM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	8/12/2016 12:00:00 AM	8/12/2016 11:09 AM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/25/2015 8:03 PM
Contacts	Primary Contact	Update		Ratliff, Krista VP 4103623116	Alabi, Esther Director of Pharmacy 4103623245	8/25/2015 8:03 PM
Details	Last Recertification Date	Update		9/8/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 8:03 PM
Contacts	Primary Contact	Update		KOMENSKI, RANDY Director-Clinical Transformation and Clinical Business Operations 4103623198	Ratliff, Krista VP 4103623116	8/25/2015 5:45 PM
Contacts	Primary Contact	Update		KREMPA, CHERYL DIRECTOR OF PHARMACY 4103623313	KOMENSKI, RANDY Director-Clinical Transformation and Clinical Business Operations 4103623198	9/8/2014 3:03 PM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	9/8/2014 12:00:00 AM	9/8/2014 3:03 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 10:11 PM
Contacts	Primary Contact	Update		AWUAH, THEO DIRECTOR OF PHARMACY 4103623313	KREMPA, CHERYL DIRECTOR OF PHARMACY 4103623313	5/22/2012 12:37 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/22/2012 12:37 PM
Contacts	Authorizing Official	Update		BRAAM, RICHARD CFO 4103623333	JONES, RICHARD CFO 4103623716	3/15/2012 1:46 PM
Dates	Participating Approval Date	Update		5/19/2008 11:34:52 AM	5/19/2008 12:00:00 AM	3/15/2012 1:46 PM
Contacts	Authorizing Official	Insert			BRAAM, RICHARD CFO 4103623333	6/30/2008 2:00 PM
Contacts	Primary Contact	Insert			AWUAH, THEO DIRECTOR OF PHARMACY 4103623313	6/30/2008 2:00 PM
Details	Last Recertification Date	Insert				5/19/2008 11:38 AM
Details	Grant Number	Insert				5/19/2008 11:38 AM
Details	340B ID	Insert			DSH210013	5/19/2008 11:38 AM
Details	Is Authorizing Official EHB Data	Insert				5/19/2008 11:38 AM
Dates	Last Date That 340B Drugs Purchased	Insert				5/19/2008 11:38 AM
Details	Medicare Provider Number	Insert			210013	5/19/2008 11:38 AM
Details	Entity Name	Insert			BON SECOURS HOSPITAL BALTIMORE, INC.	5/19/2008 11:38 AM
Details	Program Code	Insert			DSH	5/19/2008 11:38 AM
Details	Entity Subname	Insert				5/19/2008 11:38 AM
Dates	Participating Approval Date	Insert			5/19/2008 11:34:52 AM	5/19/2008 11:38 AM
Details	State	Insert			Active	5/19/2008 11:38 AM
Dates	Registration Date	Insert			5/19/2008 12:00:00 AM	5/19/2008 11:38 AM
Dates	Signed By Date	Insert				5/19/2008 11:38 AM
Dates	Start Date	Insert			10/1/2002 12:00:00 AM	5/19/2008 11:38 AM
Terminations	Termination Comments	Insert				5/19/2008 11:38 AM
Terminations	Termination Date	Insert				5/19/2008 11:38 AM
Terminations	Termination Effective Date	Insert				5/19/2008 11:38 AM
Terminations	Termination Reason	Insert				5/19/2008 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	5/19/2008 11:38 AM
Medicaid Billing	Medicaid: Number	Insert			000175900	5/19/2008 11:38 AM
Medicaid Billing	Medicaid: State	Insert			MD	5/19/2008 11:38 AM