Covered Entity Details

DSH330223 MASSENA MEMORIAL HOSPITAL (Terminated) - information as of 5/27/2025 2:24:32 PM

Main Details

Name

MASSENA MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330223

Medicare Provider Number

330223

Additional Details

Current Program Status

Terminated

Registration Date

6/15/2010

Participating Start Date

7/1/2010

Participating Approval Date

6/16/2010

Last Recertification Date

9/7/2016

Termination Date
Termination Reason

4/1/2017
Change of covered entity type

Contacts

Authorizing Official

MASSENA MEMORIAL HOSPITAL
Patrick Facteau, CFO
(315) 769-4207

Primary Contact

MASSENA MEMORIAL HOSPITAL
Melissa Bender, Accountant
(315) 769-4312

Addresses

Street Address

1 HOSPITAL DRIVE
MASSENA, NY 13662

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
6/16/10 - DOC RECD TO CONFIRM ELIG DSH ADJ %	10/13/2010

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

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	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #10	300 MAIN STREET	MASSENA	NY	13662	07/27/2011	07/27/2011	04/01/2017	03/16/2017
Contract Detail	NOBLE HEALTH SERVICES INC.	6040 TARBELL ROAD		SYRACUSE	NY	13206	04/15/2013	04/15/2013	04/01/2017	03/16/2017
Contract Detail	PROACT PHARMACY SERVICES, INC.	1226 US HIGHWAY 11		GOUVERNEUR	NY	13642	02/22/2012	02/22/2012	04/01/2017	03/16/2017
Contract Detail	RITE AID OF NEW YORK, INC.	RITE AID #4998	87 MAIN STREET	MASSENA	NY	13662	09/12/2012	09/12/2012	04/01/2017	03/16/2017
Contract Detail	WAL-MART STORES EAST, LP	WAL-MART PHARMACY 10-1946	43 STEPHENVILLE ST	MASSENA	NY	13662	01/15/2014	04/01/2014	04/01/2017	03/16/2017
Contract Detail	WALGREEN EASTERN CO INC	DBA: WALGREENS #10698	303 MAIN ST.	MASSENA	NY	13662-2546	04/15/2013	04/15/2013	04/01/2017	03/16/2017
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 10293	173 MARKET ST	POTSDAM	NY	13676-1221	04/15/2013	04/15/2013	04/01/2017	03/16/2017
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #10591	305 W. MAIN ST.	MALONE	NY	12953-1751	04/15/2013	04/15/2013	04/01/2017	03/16/2017
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/15/2013	04/15/2013	07/20/2015	03/14/2017
Contract Detail	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	04/15/2013	04/15/2013	07/20/2015	03/14/2017

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330223A	Child	DSH	MASSENA MEMORIAL HOSPITAL	MMH MEDICAL GROUP	181 MAPLE ST	MASSENA	NY	Terminated
DSH330223B	Child	DSH	MASSENA MEMORIAL HOSPITAL	CARDIAC CLINIC	181 MAPLE ST	MASSENA	NY	Terminated
DSH330223C	Child	DSH	MASSENA MEMORIAL HOSPITAL	OB/GYN CLINIC	15 HOSPITAL DR	MASSENA	NY	Terminated
DSH330223D	Child	DSH	MASSENA MEMORIAL HOSPITAL	NEUROLOGY CLINIC	181 MAPLE ST	MASSENA	NY	Terminated
DSH330223E	Child	DSH	MASSENA MEMORIAL HOSPITAL	LOISVILLE FAMILY HEALTH CENTER	10 STATE HWY 37B	MASSENA	NY	Terminated
DSH330223F	Child	DSH	MASSENA MEMORIAL HOSPITAL	MASSENA SURGICAL PRACTICE	181 MAPLE ST	MASSENA	NY	Terminated
DSH330223G	Child	DSH	MASSENA MEMORIAL HOSPITAL	MASSENA NEPHROLOGY	17 HOSPITAL DRIVE	MASSENA	NY	Terminated
DSH330223H	Child	DSH	MASSENA MEMORIAL HOSPITAL	KIDS KORNER	17 HOSPITAL DR	MASSENA	NY	Terminated
DSH330223J	Child	DSH	MASSENA MEMORIAL HOSPITAL	NORFOLK FAMILY HEALTH CENTER	42W MAIN ST	NORFOLK	NY	Terminated
DSH330223K	Child	DSH	MASSENA MEMORIAL HOSPITAL	BRASHER FALLS FAMILY HEALTH CENTER	3 CUDLIPP DR	BRASHER FALLS	NY	Terminated

History

Section	Field	Action	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Bender, Melissa Accountant 3157694312	Bender, Melissa Accountant MASSENA MEMORIAL HOSPITAL 3157694312	8/14/2019 11:04 AM
Contacts	Authorizing Official	Update	Facteau, Patrick CFO 3157694207	Facteau, Patrick CFO MASSENA MEMORIAL HOSPITAL 3157694207	10/4/2017 11:40 AM
Contacts	Authorizing Official	Update	TORTORIELLO, MICHAEL DIRECTOR OF FINANCE 3157694207	Facteau, Patrick CFO 3157694207	7/13/2017 2:33 PM
Contacts	Primary Contact	Update	MILLER, ERIC PHARMACY DIRECTOR 3157694216	Bender, Melissa Accountant 3157694312	3/16/2017 3:37 PM
Addresses	Main Address	Insert		1 HOSPITAL DRIVE MASSENA, NY 13662	3/14/2017 3:54 PM
Details	State	Update	Active	Terminated	3/14/2017 3:54 PM
Terminations	Termination Comments	Update		Registration of entity as a new entity of SCH was approved.	3/14/2017 3:54 PM
Terminations	Termination Date	Update		4/1/2017 12:00:00 AM	3/14/2017 3:54 PM
Terminations	Termination Effective Date	Update		4/1/2017 12:00:00 AM	3/14/2017 3:54 PM
Terminations	Termination Reason	Update		Change of covered entity type	3/14/2017 3:54 PM
Details	Last Recertification Date	Update	8/27/2015 12:00:00 AM	9/7/2016 12:00:00 AM	9/7/2016 9:37 AM
Contacts	Authorizing Official	Update	TIERMAN, KELLEY M. CFO 3157694207	TORTORIELLO, MICHAEL DIRECTOR OF FINANCE 3157694207	11/13/2015 3:58 PM
Contacts	Primary Contact	Insert		MILLER, ERIC PHARMACY DIRECTOR 3157694216	8/27/2015 3:59 PM
Details	Last Recertification Date	Update	8/21/2014 12:00:00 AM	8/27/2015 12:00:00 AM	8/27/2015 3:59 PM
Details	Last Recertification Date	Update	9/11/2013 12:00:00 AM	8/21/2014 12:00:00 AM	8/21/2014 2:30 PM
Details	Last Recertification Date	Update	7/1/2012 12:00:00 AM	9/11/2013 12:00:00 AM	9/11/2013 2:46 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	5/16/2012 8:12 AM
Contacts	Authorizing Official	Insert		TIERMAN, KELLEY M. CFO 3157694207	10/13/2010 11:59 AM
Details	Last Recertification Date	Insert			10/13/2010 11:59 AM
Details	Grant Number	Insert			10/13/2010 11:59 AM
Details	340B ID	Insert		DSH330223	10/13/2010 11:59 AM
Details	Is Authorizing Official EHB Data	Insert			10/13/2010 11:59 AM
Dates	Last Date That 340B Drugs Purchased	Insert			10/13/2010 11:59 AM
Details	Medicare Provider Number	Insert		330223	10/13/2010 11:59 AM
Details	Entity Name	Insert		MASSENA MEMORIAL HOSPITAL	10/13/2010 11:59 AM
Details	Program Code	Insert		DSH	10/13/2010 11:59 AM
Details	Entity Subname	Insert			10/13/2010 11:59 AM
Dates	Participating Approval Date	Insert		6/16/2010 12:00:00 AM	10/13/2010 11:59 AM
Details	State	Insert		Active	10/13/2010 11:59 AM
Dates	Registration Date	Insert		6/15/2010 12:00:00 AM	10/13/2010 11:59 AM
Dates	Signed By Date	Insert		6/1/2010 12:00:00 AM	10/13/2010 11:59 AM
Dates	Start Date	Insert		7/1/2010 12:00:00 AM	10/13/2010 11:59 AM
Terminations	Termination Comments	Insert			10/13/2010 11:59 AM
Terminations	Termination Date	Insert			10/13/2010 11:59 AM
Terminations	Termination Effective Date	Insert			10/13/2010 11:59 AM
Terminations	Termination Reason	Insert			10/13/2010 11:59 AM
Details	Comments Public	Insert		6/16/10 - DOC RECD TO CONFIRM ELIG DSH ADJ %	10/13/2010 11:59 AM