Covered Entity Details

DSH330232V SETON HEALTH SYSTEM (Terminated) - information as of 4/25/2025 12:02:02 AM

Main Details

Name

SETON HEALTH SYSTEM

Subdivision Name

Clifton Park OB/GYN

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330232V

Medicare Provider Number

330232

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/15/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/14/2015

Last Recertification Date

8/28/2018

Termination Date
Termination Reason

4/1/2019
Business decision by the Covered Entity

Contacts

Authorizing Official

Samaritan Hospital of Troy NY
Lori Santos, CFO
(518) 525-5537

Primary Contact

Samaritan Hospital of Troy NY
JEANNE KENNICUTT, MGR AMBULATORY CARE PHARMACY SERVICES
(518) 525-6132

Addresses

Street Address

855 Rt 146
CLIFTON PARK, NY 12065

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?
No

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
DSH330232A	Child	DSH	SETON HEALTH SYSTEM	ST. MARY'S HOSPITAL	1300 MASSACHUSETTS AVE	TROY	NY	Terminated
DSH330232AA	Child	DSH	SETON HEALTH	Latham Anticoagulation Clinic / Anticoagulation Clinic	1 Bell Tower Drive	Watervliet	NY	Terminated
DSH330232AB	Child	DSH	SETON HEALTH SYSTEM	Seton OB/GYN	2231 BURDETT AVE	TROY	NY	Terminated
DSH330232AC	Child	DSH	SETON HEALTH SYSTEM	SETON HEALTH SYSTEM, INC - Latham OB/GYN	713 TROY SCHENECTADY RD	LATHAM	NY	Terminated
DSH330232B	Child	DSH	SETON HEALTH SYSTEM	CLIFTON PARK Primary Care	1 TALLOW WOOD DRIVE	CLIFTON PARK	NY	Terminated
DSH330232C	Child	DSH	SETON HEALTH SYSTEM	TROY INTERNAL MEDICINE	1401 MASSACHUSETTS AVENUE	TROY	NY	Terminated
DSH330232D	Child	DSH	SETON HEALTH SYSTEM	Seton Internal Medicine - THE MASSRY CENTER	147 HOOSICK STREET	TROY	NY	Terminated
DSH330232E	Child	DSH	SETON HEALTH SYSTEM	CAPITAL REGION Primary Care	2 EMPIRE DRIVE	RENSSELAER	NY	Terminated
DSH330232F	Child	DSH	SETON HEALTH SYSTEM	MECHANICVILLE FAMILY HEALTH CENTER	202 SOUTH CENTRAL AVENUE	MECHANICVILLE	NY	Terminated
DSH330232G	Child	DSH	SETON HEALTH SYSTEM	STILLWATER FAMILY HEALTH CENTER	351 NORTH HUDSON AVENUE	STILLWATER	NY	Terminated
DSH330232J	Child	DSH	SETON HEALTH SYSTEM	SETON HEALTH PEDIATRICS	500 FEDERAL STREET	TROY	NY	Terminated
DSH330232K	Child	DSH	SETON HEALTH SYSTEM	CLIFTON PARK MEDICAL IMAGING	1 TALLOWWOOD DRIVE	CLIFTON PARK	NY	Terminated
DSH330232M	Child	DSH	SETON HEALTH SYSTEM	SCHAGHTICOKE FAMILY HEALTH CENTER	8 MEADOWVIEW DRIVE	SCHAGHTICOKE	NY	Terminated
DSH330232N	Child	DSH	SETON HEALTH SYSTEM	Capital Region Family Health Urgent Care	2 EMPIRE DR	RENSSELAER	NY	Terminated
DSH330232P	Child	DSH	SETON HEALTH SYSTEM	Clifton Park Urgent Care	1 TALLOW WOOD DR	CLIFTON PARK	NY	Terminated
DSH330232Q	Child	DSH	SETON HEALTH SYSTEM	Massry Anticoagulation Clinic	147 HOOSICK ST	TROY	NY	Terminated
DSH330232R	Child	DSH	SETON HEALTH SYSTEM	Cohoes OB/GYN	COHOES COMMONS 55 MOHAWK ST	COHOES	NY	Terminated
DSH330232S	Child	DSH	SETON HEALTH SYSTEM	CLIFTON PARK PEDIATRICS CENTER	1 TALLOW WOOD DR	CLIFTON PARK	NY	Terminated
DSH330232T	Child	DSH	SETON HEALTH SYSTEM	Latham Primary Care (Shaker Point)	1 Bell Tower Drive	Watervliet	NY	Terminated
DSH330232U	Child	DSH	SETON HEALTH SYSTEM	Capital Region OB/GYN	2 EMPIRE DR	RENSSELAER	NY	Terminated
DSH330232V	Child	DSH	SETON HEALTH SYSTEM	Clifton Park OB/GYN	855 Rt 146	CLIFTON PARK	NY	Terminated
DSH330232W	Child	DSH	SETON HEALTH SYSTEM	Clifton Park Anticoagulation Clinic	1 TALLOW WOOD DR	CLIFTON PARK	NY	Terminated
DSH330232X	Child	DSH	SETON HEALTH SYSTEM	Massry Hyperbariatric Medicine	147 HOOSICK ST	TROY	NY	Terminated
DSH330232Y	Child	DSH	SETON HEALTH SYSTEM	Massry Women's Imaging	147 HOOSICK ST	TROY	NY	Terminated
DSH330232Z	Child	DSH	SETON HEALTH SYSTEM	Massry Incontinence - Wound Care	147 HOOSICK ST	TROY	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Santos, Lori CFO Seton-St. Mary's 5185253357	Santos, Lori CFO Samaritan Hospital of Troy NY 5185255537	11/11/2019 2:42 PM
Contacts	Primary Contact	Update	Profile Change Request	KENNICUTT, JEANNE MGR AMBULATORY CARE PHARMACY SERVICES Seton Health, St. Mary's Hospital 5185256132	KENNICUTT, JEANNE MGR AMBULATORY CARE PHARMACY SERVICES Samaritan Hospital of Troy NY 5185256132	11/8/2019 10:36 AM
Details	State	Update		To Be Terminated	Terminated	4/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/31/2018 12:00:00 AM	1/2/2019 10:20 AM
Details	State	Update	Termination Request	Active	To Be Terminated	1/2/2019 10:20 AM
Terminations	Termination Comments	Update	Termination Request		Merger 1/1/2019 with Samaritan Hospital DSH330180	1/2/2019 10:20 AM
Terminations	Termination Date	Update	Termination Request		4/1/2019 12:00:00 AM	1/2/2019 10:20 AM
Terminations	Termination Effective Date	Update	Termination Request		1/1/2019 12:00:00 AM	1/2/2019 10:20 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	1/2/2019 10:20 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 4:24:21 PM	8/28/2018 1:49:37 PM	8/28/2018 1:49 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/15/2017 4:24:21 PM	11/15/2017 4:24 PM
Contacts	Authorizing Official	Update		Santos, Lori CFO 5185253357	Santos, Lori CFO Seton-St. Mary's 5185253357	10/3/2017 6:18 PM
Contacts	Primary Contact	Update		KENNICUTT, JEANNE MGR AMBULATORY CARE PHARMACY SERVICES 5185256132	KENNICUTT, JEANNE MGR AMBULATORY CARE PHARMACY SERVICES Seton Health, St. Mary's Hospital 5185256132	9/25/2017 10:14 AM
Contacts	Primary Contact	Update		Hoffman, Kathleen Director, Finance 5182754265	KENNICUTT, JEANNE MGR AMBULATORY CARE PHARMACY SERVICES 5185256132	4/18/2017 7:33 AM
Contacts	Authorizing Official	Insert			Santos, Lori CFO 5185253357	4/18/2017 7:33 AM
Contacts	Signed By	Insert			Kochie, Daniel CFO 5182685335	4/3/2017 8:36 AM
Addresses	Main Address	Insert			855 Rt 146 CLIFTON PARK, NY 12065	4/3/2017 8:35 AM
Details	Entity Name	Update		SETON HEALTH	SETON HEALTH SYSTEM	4/3/2017 8:35 AM
Details	Entity Subname	Update		SETON HEALTH SYSTEM INC / SETON HEALTH OB - Prenatal Care	Clifton Park OB/GYN	4/3/2017 8:35 AM
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 4:23 PM
Contacts	Primary Contact	Insert			Hoffman, Kathleen Director, Finance 5182754265	1/22/2016 3:56 PM
Details	Entity Subname	Update		SETON HEALTH SYSTEM INC / OB - Prenatal Care	SETON HEALTH SYSTEM INC / SETON HEALTH OB - Prenatal Care	11/13/2015 3:57 PM
Details	Last Recertification Date	Update			9/3/2015 12:00:00 AM	9/3/2015 4:31 PM
Dates	Participating Approval Date	Update			5/14/2015 12:00:00 AM	5/14/2015 11:13 AM
Details	State	Update		Pending	Active	5/14/2015 11:13 AM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/14/2015 11:13 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_51607	DSH330232V	4/23/2015 1:43 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_51607	4/15/2015 1:09 PM
Details	Last Recertification Date	Insert				4/15/2015 1:09 PM
Details	Grant Number	Insert				4/15/2015 1:09 PM
Details	340B ID	Insert				4/15/2015 1:09 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2015 1:09 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2015 1:09 PM
Details	Medicare Provider Number	Insert			330232	4/15/2015 1:09 PM
Details	Entity Name	Insert			SETON HEALTH	4/15/2015 1:09 PM
Details	Program Code	Insert			DSH	4/15/2015 1:09 PM
Details	Entity Subname	Insert			SETON HEALTH SYSTEM INC / OB - Prenatal Care	4/15/2015 1:09 PM
Dates	Participating Approval Date	Insert				4/15/2015 1:09 PM
Details	State	Insert			Pending	4/15/2015 1:09 PM
Dates	Registration Date	Insert			4/15/2015 12:00:00 AM	4/15/2015 1:09 PM
Dates	Signed By Date	Insert			4/15/2015 12:00:00 AM	4/15/2015 1:09 PM
Dates	Start Date	Insert				4/15/2015 1:09 PM
Terminations	Termination Comments	Insert				4/15/2015 1:09 PM
Terminations	Termination Date	Insert				4/15/2015 1:09 PM
Terminations	Termination Effective Date	Insert				4/15/2015 1:09 PM
Terminations	Termination Reason	Insert				4/15/2015 1:09 PM