Covered Entity Details

DSH220001B HealthAlliance-Clinton Hospital (Active) - information as of 4/30/2025 10:56:11 PM

Main Details

Name

HealthAlliance-Clinton Hospital

Subdivision Name

Oncology BH

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220001B

Medicare Provider Number

220001

Outpatient Facility Provider Number

220001

Additional Details

Current Program Status

Active

Registration Date

7/11/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/8/2014

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Marlborough Hospital
Steven McCue, Chief Financial Officer
(508) 486-5804

Primary Contact

UMass Memorial HealthAlliance-Clinton Hospital
Richard Bautz, Director of Pharmacy
(774) 437-3741

Addresses

Street Address

275 Nichols Road
Fitchburg, MA 01420

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
MA		1013995133,1285171934
CT		1013995133
RI		1013995133

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
DSH220001A	Child	DSH	HealthAlliance-Clinton Hospital		275 NICHOLS ROAD	FITCHBURG	MA	Terminated
DSH220001B	Child	DSH	HealthAlliance-Clinton Hospital	Oncology BH	275 Nichols Road	Fitchburg	MA	Active
DSH220001C	Child	DSH	HealthAlliance-Clinton Hospital	Infusion Clinic	275 Nichols Road	Fitchburg	MA	Active
DSH220001D	Child	DSH	HEALTHALLIANCE HOSPITALS, INC.	Emergency Room BH	275 Nichols Road	Fitchburg	MA	Terminated
DSH220001E	Child	DSH	HealthAlliance-Clinton Hospital	Fitchburg Family Practice	326 Nichols Road	Fitchburg	MA	Active
DSH220001F	Child	DSH	HealthAlliance-Clinton Hospital	Leominster Urgent Care	510 North Main Street	Leominster	MA	Active
DSH220001G	Child	DSH	HealthAlliance-Clinton Hospital	HEALTHALLIANCE CLINTON-CLINTON CAM - HA CLINTON AMBULATORY CARE CLINICS	201 HIGHLAND ST	CLINTON	MA	Active
DSH220001H	Child	DSH	HealthAlliance-Clinton Hospital	HAH FITCHBURG FAMILY PRACTICE - Diabetes	326 NICHOLS RD	FITCHBURG	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/22/2023 10:18:43 AM	8/12/2024 2:56:39 PM	8/12/2024 2:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1013995133 (ME)		6/6/2024 3:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285171934	3/10/2024 12:39 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	3/10/2024 12:39 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 3:46:20 PM	8/22/2023 10:18:43 AM	8/22/2023 10:18 AM
Contacts	Primary Contact	Update	Change Request	Marois, Monique Pharmacy Operations Coordinator Health Alliance - Clinton 9784662534	Bautz, Richard Director of Pharmacy UMass Memorial HealthAlliance-Clinton Hospital 7744373741	5/26/2023 10:33 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	008016296 (CT)		4/24/2023 8:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003044559 (CT)		4/24/2023 8:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1013995133 (ME)		4/24/2023 8:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0220001 (RI)		4/24/2023 8:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	OP20001 (RI)		4/24/2023 8:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1200313 (MA)		4/24/2023 8:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3082780 (NH)		12/15/2022 5:08 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0220001 (VT)		12/15/2022 5:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013995133	12/15/2022 5:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	12/15/2022 5:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013995133	12/15/2022 5:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		RI	12/15/2022 5:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013995133	12/15/2022 5:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	12/15/2022 5:08 PM
Details	Last Recertification Date	Update	Recertification	9/8/2021 2:52:17 PM	9/8/2022 3:46:20 PM	9/8/2022 3:46 PM
Contacts	Primary Contact	Update	Change Request	McCabe, Lisa Ann Sr. Director, Pharmacy Services HealthAlliance-Clinton Hospital 7744373741	Marois, Monique Pharmacy Operations Coordinator Health Alliance - Clinton 9784662534	1/28/2022 11:19 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 10:12:40 AM	9/8/2021 2:52:17 PM	9/8/2021 2:52 PM
Contacts	Primary Contact	Update	Profile Change Request	McCabe, Lisa Director of Pharmacy Health Alliance Hospital 7744373741	McCabe, Lisa Ann Sr. Director, Pharmacy Services HealthAlliance-Clinton Hospital 7744373741	1/19/2021 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		008016296	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003044559	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1013995133	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3082780	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NH	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0220001	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		RI	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0220001	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		OP20001	8/27/2020 10:12 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		RI	8/27/2020 10:12 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1013995133	8/27/2020 10:12 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/27/2020 10:12 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1013995133 ( )		8/27/2020 10:12 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 10:36:49 AM	8/27/2020 10:12:40 AM	8/27/2020 10:12 AM
Contacts	Authorizing Official	Update	Change Request	Weymouth, Deborah President, CEO Health Alliance Hospital 9784662190	McCue, Steven Chief Financial Officer Marlborough Hospital 5084865804	10/9/2019 7:48 AM
Details	Entity Name	Update	Recertification	HEALTHALLIANCE HOSPITALS, INC.	HealthAlliance-Clinton Hospital	9/15/2019 8:18 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 3:08:03 PM	8/29/2019 10:36:49 AM	8/29/2019 10:36 AM
Details	Last Recertification Date	Update	Recertification	11/17/2017 10:11:12 AM	8/23/2018 3:08:03 PM	8/23/2018 3:08 PM
Contacts	Primary Contact	Update	Change Request	Ostriker, Scott Pharmacy Director Health Alliance Hospital 9784662535	McCabe, Lisa Director of Pharmacy Health Alliance Hospital 7744373741	12/19/2017 3:53 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/17/2017 10:11:12 AM	11/17/2017 10:11 AM
Contacts	Primary Contact	Update		Ostriker, Scott Pharmacy Director 9784662535	Ostriker, Scott Pharmacy Director Health Alliance Hospital 9784662535	10/20/2017 12:43 PM
Contacts	Authorizing Official	Update		Weymouth, Deborah President, CEO 9784662190	Weymouth, Deborah President, CEO Health Alliance Hospital 9784662190	10/18/2017 11:35 AM
Contacts	Primary Contact	Insert			Ostriker, Scott Pharmacy Director 9784662535	5/17/2017 12:28 PM
Contacts	Authorizing Official	Insert			Weymouth, Deborah President, CEO 9784662190	1/4/2017 10:30 AM
Contacts	Signed By	Insert			Cofone, Mike CFO 9784662185	1/4/2017 10:29 AM
Addresses	Main Address	Insert			275 Nichols Road Fitchburg, MA 01420	8/17/2016 6:19 PM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 1:30 PM
Details	Last Recertification Date	Update			8/24/2015 12:00:00 AM	8/24/2015 1:19 PM
Dates	Participating Approval Date	Update			9/8/2014 12:00:00 AM	9/8/2014 3:11 PM
Details	State	Update		Pending	Active	9/8/2014 3:11 PM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/8/2014 3:11 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45356	DSH220001B	9/4/2014 3:09 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_45356	7/11/2014 3:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/11/2014 3:16 PM
Medicaid Billing	Medicaid: Number	Insert			1200313	7/11/2014 3:16 PM
Medicaid Billing	Medicaid: State	Insert			MA	7/11/2014 3:16 PM
Medicaid Billing	NPI: Number	Insert			1013995133	7/11/2014 3:16 PM
Details	Last Recertification Date	Insert				7/11/2014 3:16 PM
Details	Grant Number	Insert				7/11/2014 3:16 PM
Details	340B ID	Insert				7/11/2014 3:16 PM
Details	Is Authorizing Official EHB Data	Insert				7/11/2014 3:16 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/11/2014 3:16 PM
Details	Medicare Provider Number	Insert			220001	7/11/2014 3:16 PM
Details	Entity Name	Insert			HEALTHALLIANCE HOSPITALS, INC.	7/11/2014 3:16 PM
Details	Program Code	Insert			DSH	7/11/2014 3:16 PM
Details	Entity Subname	Insert			Oncology BH	7/11/2014 3:16 PM
Dates	Participating Approval Date	Insert				7/11/2014 3:16 PM
Details	State	Insert			Pending	7/11/2014 3:16 PM
Dates	Registration Date	Insert			7/11/2014 12:00:00 AM	7/11/2014 3:16 PM
Dates	Signed By Date	Insert			7/11/2014 12:00:00 AM	7/11/2014 3:16 PM
Dates	Start Date	Insert				7/11/2014 3:16 PM
Terminations	Termination Comments	Insert				7/11/2014 3:16 PM
Terminations	Termination Date	Insert				7/11/2014 3:16 PM
Terminations	Termination Effective Date	Insert				7/11/2014 3:16 PM
Terminations	Termination Reason	Insert				7/11/2014 3:16 PM