Covered Entity Details

DSH310084E Monmouth Medical Center Southern Campus (Terminated) - information as of 5/26/2025 12:53:01 AM

Main Details

Name

Monmouth Medical Center Southern Campus

Subdivision Name

Rehabilitative and Occupational Health Services Therapy Center / Audiology and Speech Therapy

Type

Disproportionate Share Hospital

Rural

340B ID

DSH310084E

Medicare Provider Number

310084

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/10/2015

Participating Start Date

10/1/2015

Participating Approval Date

8/20/2015

Last Recertification Date

8/30/2016

Termination Date
Termination Reason

4/1/2017
DSH percentage below statutory minimum

Contacts

Authorizing Official

RWJBarnabas Health
Nikolas Alexiades, CFO
(973) 926-7824

Primary Contact

RWJBarnabas
Robert Pellechio, VICE PRESIDENT, Corp Pharmacy
(973) 322-4327

Addresses

Street Address

500 River Ave
Lakewood, NJ 08701

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
NJ	3676200
		1225133473

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
DSH310084A	Child	DSH	Monmouth Medical Center Southern Campus	Jacqueline M. Wilentz Breast Center / Screening & Diagnostic Mammography	500 River Ave. Suite 200	Lakewood	NJ	Terminated
DSH310084B	Child	DSH	Monmouth Medical Center Southern Campus	Rehabilitative and Occupational Health Services Therapy Center / Occupational Therapy	500 River Ave	Lakewood	NJ	Terminated
DSH310084C	Child	DSH	Monmouth Medical Center Southern Campus	Rehabilitative and Occupational Health Services Therapy Center / Physical Therapy	500 River Ave, Suite 100	Lakewood	NJ	Terminated
DSH310084D	Child	DSH	Monmouth Medical Center Southern Campus	Jacqueline M. Wilentz Breast Center / Bone Mineral Density Study, Ultrasound	500 River Ave, Suite 200	Lakewood	NJ	Terminated
DSH310084E	Child	DSH	Monmouth Medical Center Southern Campus	Rehabilitative and Occupational Health Services Therapy Center / Audiology and Speech Therapy	500 River Ave	Lakewood	NJ	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Zimmerman, Joanna Chief Financial Officer Monmouth Medical Center 7329237181	Alexiades, Nikolas CFO RWJBarnabas Health 9739267824	6/12/2019 10:53 AM
Contacts	Authorizing Official	Update		Zimmerman, Joanna Chief Financial Officer 7329237181	Zimmerman, Joanna Chief Financial Officer Monmouth Medical Center 7329237181	11/14/2017 4:30 PM
Contacts	Primary Contact	Update		Pellechio, Robert VICE PRESIDENT, Corp Pharmacy 9733224327	Pellechio, Robert VICE PRESIDENT, Corp Pharmacy RWJBarnabas 9733224327	9/19/2017 10:37 AM
Contacts	Primary Contact	Insert			Pellechio, Robert VICE PRESIDENT, Corp Pharmacy 9733224327	8/8/2017 9:19 AM
Contacts	Authorizing Official	Insert			Zimmerman, Joanna Chief Financial Officer 7329237181	4/5/2017 11:36 AM
Addresses	Main Address	Insert			500 River Ave Lakewood, NJ 08701	1/12/2017 10:10 AM
Contacts	Signed By	Insert			McClung, David CFO 7329237181	1/12/2017 10:10 AM
Dates	Last Date That 340B Drugs Purchased	Update			10/15/2016 12:00:00 AM	1/12/2017 10:10 AM
Details	State	Update		Active	Terminated	1/12/2017 10:10 AM
Terminations	Termination Comments	Update			The eligible child site was closed and moved to within the four walls of the covered entity. Apexus advised to use the move date as the “term date” and “last 340B purchase date” with a reason of “DSH percentage below statutory minimum” because HRSA/OPA will update the reason to the real reason when processed. Apexus instructed me to leave these comments to clarify the request.	1/12/2017 10:10 AM
Terminations	Termination Date	Update			4/1/2017 12:00:00 AM	1/12/2017 10:10 AM
Terminations	Termination Effective Date	Update			10/15/2016 12:00:00 AM	1/12/2017 10:10 AM
Terminations	Termination Reason	Update			DSH percentage below statutory minimum	1/12/2017 10:10 AM
Details	Entity Name	Update		KIMBALL MEDICAL CENTER	Monmouth Medical Center Southern Campus	12/16/2016 3:03 PM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 3:36 PM
Dates	Participating Approval Date	Update			8/20/2015 12:00:00 AM	8/20/2015 4:02 PM
Details	State	Update		Pending	Active	8/20/2015 4:02 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	8/20/2015 4:02 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_53124	DSH310084E	8/19/2015 4:21 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_53124	7/10/2015 5:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/10/2015 5:22 PM
Medicaid Billing	Medicaid: Number	Insert			3676200	7/10/2015 5:22 PM
Medicaid Billing	Medicaid: State	Insert			NJ	7/10/2015 5:22 PM
Medicaid Billing	NPI: Number	Insert			1225133473	7/10/2015 5:22 PM
Details	Last Recertification Date	Insert				7/10/2015 5:22 PM
Details	Grant Number	Insert				7/10/2015 5:22 PM
Details	340B ID	Insert				7/10/2015 5:22 PM
Details	Is Authorizing Official EHB Data	Insert				7/10/2015 5:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/10/2015 5:22 PM
Details	Medicare Provider Number	Insert			310084	7/10/2015 5:22 PM
Details	Entity Name	Insert			KIMBALL MEDICAL CENTER	7/10/2015 5:22 PM
Details	Program Code	Insert			DSH	7/10/2015 5:22 PM
Details	Entity Subname	Insert			Rehabilitative and Occupational Health Services Therapy Center / Audiology and Speech Therapy	7/10/2015 5:22 PM
Dates	Participating Approval Date	Insert				7/10/2015 5:22 PM
Details	State	Insert			Pending	7/10/2015 5:22 PM
Dates	Registration Date	Insert			7/10/2015 12:00:00 AM	7/10/2015 5:22 PM
Dates	Signed By Date	Insert			7/10/2015 12:00:00 AM	7/10/2015 5:22 PM
Dates	Start Date	Insert				7/10/2015 5:22 PM
Terminations	Termination Comments	Insert				7/10/2015 5:22 PM
Terminations	Termination Date	Insert				7/10/2015 5:22 PM
Terminations	Termination Effective Date	Insert				7/10/2015 5:22 PM
Terminations	Termination Reason	Insert				7/10/2015 5:22 PM