Covered Entity Details

SCH330157-00 SAMARITAN MEDICAL CENTER (Terminated) - information as of 5/16/2025 11:27:00 PM

Main Details

Name

SAMARITAN MEDICAL CENTER

Subdivision Name

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH330157-00

Medicare Provider Number

330157

Additional Details

Current Program Status

Terminated

Registration Date

7/14/2011

Participating Start Date

10/1/2017

Participating Approval Date

9/11/2011

Last Recertification Date

9/16/2019

Termination Date
Termination Reason

10/1/2020
Change of covered entity type

Contacts

Authorizing Official

Samaritan Medical Center
Maxine A Briggs, VP Of Fiscal Services/Chief Financial Officer
(315) 755-3605

Primary Contact

Samaritan Medical Center
Krista Ann Krull-Goss, Director of Pharmacy
(315) 785-4248

Addresses

Street Address

830 WASHINGTON STREET
WATERTOWN, NY 13601

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
8/4/17; Participating 10/1/2011 until terminated effective 10/1/2013, reinstated effective 10/1/2017.	08/04/2017

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	00354316,03001609,03001594
		1093722068,1801902713,1598713745

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	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	01/14/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #42	21 NYS ROUTE 12	ALEXANDRIA BAY	NY	13607	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #48	822 JAMES STREET	CLAYTON	NY	13624	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #34	371 EAST MAIN ST	GOUVERNEUR	NY	13642	08/08/2017	10/01/2017	03/15/2019	03/19/2019
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #24	3873 ROME ROAD	PULASKI	NY	13142	08/08/2017	10/01/2017	03/15/2019	03/19/2019
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #20	7395 UTICA BLVD	LOWVILLE	NY	13367	08/08/2017	10/01/2017	03/15/2019	03/19/2019
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #15	1304 WASHINGTON ST	WATERTOWN	NY	13601	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #13	1729 STATE STREET	WATERTOWN	NY	13601	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #06	401 STATE STREET	CARTHAGE	NY	13619	08/08/2017	10/01/2017	03/15/2019	03/19/2019
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #08	22056 U.S. ROUTE 11	WATERTOWN	NY	13601	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #04	10923 US ROUTE 11	ADAMS	NY	13605	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #01	17 CLINTON STREET	GOUVERNEUR	NY	13642	08/08/2017	10/01/2017	03/15/2019	03/19/2019
Contract Detail	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #30	905 COFFEEN STREET	WATERTOWN	NY	13601	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	NOBLE HEALTH SERVICES INC.	6040 TARBELL ROAD		SYRACUSE	NY	13206	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	04/07/2020	07/01/2020	10/01/2020	10/01/2020
Contract Detail	PROACT PHARMACY SERVICES, INC.	1226 US HIGHWAY 11		GOUVERNEUR	NY	13642	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/07/2020	07/01/2020	10/01/2020	10/01/2020
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/07/2020	07/01/2020	10/01/2020	10/01/2020
Contract Detail	SORKIN'S RX LTD	D/B/A CAREMED PHARMACEUTICAL SERVICES	1985 MARCUS AVE STE 130	NEW HYDE PARK	NY	11042-2024	04/07/2020	07/01/2020	10/01/2020	10/01/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/08/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	WAL-MART PHARMACY 10-1871	20823 ST. - RT. #3		WATERTOWN	NY	13601	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5497	25737 US ROUTE #11		EVANS MILLS	NY	13637	08/08/2017	10/01/2017	10/01/2020	10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/08/2020	04/01/2020	10/01/2020	10/01/2020
Contract Detail	WEGMANS FOOD MARKETS, INC.	2851 BROADWAY	ATTN: PHARMACY	CHEEKTOWAGA	NY	14227	01/08/2020	04/01/2020	10/01/2020	10/01/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
SCH330157-01	Child	SCH	SAMARITAN MEDICAL CENTER	Pain Clinic	830 Washington Street	Watertown	NY	Terminated
SCH330157-02	Child	SCH	SAMARITAN MEDICAL CENTER	A Women's Perspective OB/GYN Clinic	22567 Summit Drive., Bldg 2, Ste. C	Watertown	NY	Terminated
SCH330157-03	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Wound Care Clinic	165 COLEMAN AVE	WATERTOWN	NY	Terminated
SCH330157-04	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FAMILY HEALTH CENTER - Samaritan Health Sackets Harbor Clinic	105 BARRACKS DR	SACKETS HARBOR	NY	Terminated
SCH330157-05	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health LaCona Clinic	3 DEMOTT ST	LACONA	NY	Terminated
SCH330157-06	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Clayton Clinic	909 STRAWBERRY LANE	CLAYTON	NY	Terminated
SCH330157-07	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FAMILY HEALTH CENTER - Samaritan Health Adams Clinic	10881 US ROUTE 11	ADAMS	NY	Terminated
SCH330157-08	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Washington Street Plaza Clinic	1575 WASHINGTON ST	WATERTOWN	NY	Terminated
SCH330157-09	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FAMILY HEALTH CENTER - Samaritan Health Urology Clinic	22567 SUMMIT DRIVE	WATERTOWN	NY	Terminated
SCH330157-10	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN URGENT CARE - Samaritan Health LeRay Urgent Care	26908 INDEPENDENCE WAY	EVANS MILLS	NY	Terminated
SCH330157-11	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - SMC Alcohol/Chemical Dependency Clinic	1575 WASHINGTON ST	WATERTOWN	NY	Terminated
SCH330157-12	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Behavioral Health Clinic	1575 WASHINGTON ST	WATERTOWN	NY	Terminated
SCH330157-13	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FAMILY HEALTH CENTER - Samaritan Health LeRay Clinic	26908 Independence Way	EVANS MILLS	NY	Terminated
SCH330157-14	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - WOMEN'S WELLNESS & BREAST CARE	1575 WASHINGTON ST	WATERTOWN	NY	Terminated
SCH330157-15	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FMAILY HEALTH CENTER - Samaritan Health Cape Vincent Clinic	782 EAST BROADWAY ST	CAPE VINCENT	NY	Terminated
SCH330157-16	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Dermatology Clinic	830 WASHINGTON STREET	WATERTOWN	NY	Terminated
SCH330157-17	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - RHEUMATOLOGY - RHEUMATOLOGY	629 WASHINGTON STREET	WATERTOWN	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	7/16/2020 12:41 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	7/16/2020 12:41 PM
Terminations	Termination Date	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	7/16/2020 12:41 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	7/16/2020 12:41 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	7/16/2020 12:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/11/2020 8:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00354316	3/11/2020 8:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	3/11/2020 8:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/11/2020 8:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03001609	3/11/2020 8:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	3/11/2020 8:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/11/2020 8:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03001594	3/11/2020 8:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	3/11/2020 8:03 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1093722068	3/11/2020 8:03 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1801902713	3/11/2020 8:03 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1598713745	3/11/2020 8:03 AM
Contacts	Authorizing Official	Update	AO Change Request	Carman, Thomas H. President & CEO Samaritan Medical Center 3157854121	Briggs, Maxine A VP Of Fiscal Services/Chief Financial Officer Samaritan Medical Center 3157553605	1/30/2020 8:22 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 6:55:20 AM	9/16/2019 1:49:01 PM	9/16/2019 1:49 PM
Contacts	Primary Contact	Update	Profile Change Request	Krull-Goss, Krista Ann Assistant Director of Pharmacy Samaritan Medical Center 3157854248	Krull-Goss, Krista Ann Director of Pharmacy Samaritan Medical Center 3157854248	3/15/2019 2:15 PM
Details	Last Recertification Date	Update	Recertification	11/4/2017 1:15:16 PM	8/23/2018 6:55:20 AM	8/23/2018 6:55 AM
Contacts	Primary Contact	Update	Change Request	Sanzone, Joseph Director of Pharmacy Samaritan Medical Center 3157854293	Krull-Goss, Krista Ann Assistant Director of Pharmacy Samaritan Medical Center 3157854248	7/30/2018 2:50 PM
Details	Last Recertification Date	Update	Recertification		11/4/2017 1:15:16 PM	11/4/2017 1:15 PM
Contacts	Authorizing Official	Update	New Registration	Carman, Thomas H. President & CEO 3157854121	Carman, Thomas H. President & CEO Samaritan Medical Center 3157854121	10/11/2017 8:54 AM
Contacts	Primary Contact	Update		Sanzone, Joseph Director of Pharmacy 3157854293	Sanzone, Joseph Director of Pharmacy Samaritan Medical Center 3157854293	9/25/2017 1:53 PM
Contacts	Primary Contact	Update		Mehaffy, Sue 340B Coordinator 3157795147	Sanzone, Joseph Director of Pharmacy 3157854293	8/10/2017 5:22 PM
Contacts	Authorizing Official	Insert			Carman, Thomas H. President & CEO 3157854121	8/10/2017 5:22 PM
Addresses	Main Address	Insert			830 WASHINGTON STREET WATERTOWN, NY 13601	8/4/2017 10:09 AM
Details	State	Update		Approved	Active	8/4/2017 10:09 AM
Details	Last Recertification Date	Update		9/10/2013 12:00:00 AM		8/4/2017 10:08 AM
Dates	Last Date That 340B Drugs Purchased	Update		10/1/2013 12:00:00 AM		8/4/2017 10:08 AM
Details	State	Update		Terminated	Approved	8/4/2017 10:08 AM
Dates	Start Date	Update		10/1/2011 12:00:00 AM	10/1/2017 12:00:00 AM	8/4/2017 10:08 AM
Terminations	Termination Date	Update		10/1/2013 12:00:00 AM		8/4/2017 10:08 AM
Terminations	Termination Effective Date	Update		10/1/2013 12:00:00 AM		8/4/2017 10:08 AM
Terminations	Termination Reason	Update		DSH percentage below statutory minimum		8/4/2017 10:08 AM
Details	Comments Public	Insert			8/4/17; Participating 10/1/2011 until terminated effective 10/1/2013, reinstated effective 10/1/2017.	8/4/2017 10:08 AM
Contacts	Primary Contact	Insert			Mehaffy, Sue 340B Coordinator 3157795147	7/3/2014 4:20 PM
Dates	Last Date That 340B Drugs Purchased	Update			10/1/2013 12:00:00 AM	7/3/2014 4:20 PM
Terminations	Termination Effective Date	Update			10/1/2013 12:00:00 AM	7/3/2014 4:20 PM
Details	Last Recertification Date	Update			9/10/2013 12:00:00 AM	9/10/2013 11:50 AM
Details	State	Update		Active	Terminated	9/10/2013 11:50 AM
Terminations	Termination Date	Update			10/1/2013 12:00:00 AM	9/10/2013 11:50 AM
Terminations	Termination Reason	Update			DSH percentage below statutory minimum	9/10/2013 11:50 AM
Dates	Participating Approval Date	Update			9/11/2011 12:00:00 AM	9/11/2011 6:06 PM
Details	State	Update		Pending	Active	9/11/2011 6:06 PM
Dates	Start Date	Update			10/1/2011 12:00:00 AM	8/25/2011 5:57 PM
Details	340B ID	Update		ONLINE_REG	SCH330157-00	8/11/2011 5:47 PM
Details	Last Recertification Date	Insert				7/14/2011 11:40 AM
Details	Grant Number	Insert				7/14/2011 11:40 AM
Details	340B ID	Insert			ONLINE_REG	7/14/2011 11:40 AM
Details	Is Authorizing Official EHB Data	Insert				7/14/2011 11:40 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/14/2011 11:40 AM
Details	Medicare Provider Number	Insert			330157	7/14/2011 11:40 AM
Details	Entity Name	Insert			SAMARITAN MEDICAL CENTER	7/14/2011 11:40 AM
Details	Program Code	Insert			SCH	7/14/2011 11:40 AM
Details	Entity Subname	Insert				7/14/2011 11:40 AM
Dates	Participating Approval Date	Insert				7/14/2011 11:40 AM
Details	State	Insert			Pending	7/14/2011 11:40 AM
Dates	Registration Date	Insert			7/14/2011 12:00:00 AM	7/14/2011 11:40 AM
Dates	Signed By Date	Insert				7/14/2011 11:40 AM
Dates	Start Date	Insert				7/14/2011 11:40 AM
Terminations	Termination Comments	Insert				7/14/2011 11:40 AM
Terminations	Termination Date	Insert				7/14/2011 11:40 AM
Terminations	Termination Effective Date	Insert				7/14/2011 11:40 AM
Terminations	Termination Reason	Insert				7/14/2011 11:40 AM