Covered Entity Details

DSH330259 MERCY MEDICAL CENTER (Active) - information as of 6/7/2025 4:45:15 AM

Main Details

Name

MERCY MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330259

Medicare Provider Number

330259

Additional Details

Current Program Status

Active

Registration Date

10/9/2015

Participating Start Date

1/1/2016

Participating Approval Date

11/5/2015

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Mercy Medical Center
Ihab Ibrahim, Chief Operating Officer/Director of Pharmacy
(516) 705-6480

Primary Contact

Catholic HEALTH
AnneMarie Keiscier, Pharmacy director
(516) 705-1053

Addresses

Street Address

1000 NORTH VILLAGE AVE
ROCKVILLE CENTRE, NY 11570

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	4161106	1659330173,1427017854,1598724924
CT	008041851	1427017854,1598724924,1659330173
FL	091257300	1427017854,1598724924,1659330173
PA	0017745260001	1427017854,1598724924,1659330173
NY	02996725,02969111,02969102	1427017854,1598724924,1659330173

Shipping Addresses

Shipping Address 1

Safecor Health
317 New Boston Street
Suite #100
Woburn, MA 01801

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	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/11/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/11/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/11/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/11/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/11/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	10/11/2023	01/01/2024		01/01/2024
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/11/2023	01/01/2024		01/01/2024
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	10/11/2023	01/01/2024		01/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	10/11/2023	01/01/2024		01/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	10/11/2023	01/01/2024		01/01/2024
Contract Detail	FONTAK INC	DBA RYAN MEDICAL PHARMACY	2000 NORTH VILLAGE AVENUE SUITE 107	ROCKVILLE CENTRE	NY	11570	12/02/2015	01/01/2016	12/31/2020	01/22/2021
Contract Detail	GENOVESE DRUG STORES, INC.	RITE AID #10615	23 EAST PARK AVENUE	LONG BEACH	NY	11561	07/12/2022	10/01/2022	10/01/2023	10/20/2023
Contract Detail	GENOVESE DRUG STORES, INC.	RITE AID #10620	198 WEST MERRICK ROAD	VALLEY STREAM	NY	11580	07/12/2022	10/01/2022	10/01/2023	10/20/2023
Contract Detail	MY CHS RX INC	1000 N VILLAGE AVE # K700		ROCKVILLE CENTRE	NY	11570-1000	04/07/2020	07/01/2020		07/01/2020
Contract Detail	MY CHS RX INC.	4295 HEMPSTEAD TPKE STE 14		BETHPAGE	NY	11714	01/09/2020	04/01/2020		04/01/2020
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	10/11/2024	01/01/2025		01/01/2025
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	10/11/2024	01/01/2025		01/01/2025
Contract Detail	ST. JOSEPH HOSPITAL	ATTN: PHARMACY DEPARTMENT	4295 HEMPSTEAD TPKE	BETHPAGE	NY	11714	07/11/2019	10/01/2019	01/01/2020	01/09/2020
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03457	393 FRONT ST	HEMPSTEAD	NY	11550	01/12/2017	04/01/2017		06/30/2017
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04845	89 HENRY STREET	FREEPORT	NY	11520	01/12/2017	04/01/2017		06/30/2017
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 06823	1968 GRAND AVE	NORTH BALDWIN	NY	11510-2813	01/12/2017	04/01/2017		06/30/2017
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	603 UNIONDALE AVE.	UNIONDALE	NY	11553-2637	01/12/2017	04/01/2017		06/30/2017

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330259A	Child	DSH	MERCY MEDICAL CENTER	Family Counseling Services	506 Stewart AVE	GARDEN CITY	NY	Active
DSH330259B	Child	DSH	MERCY MEDICAL CENTER	Mental Health Clinic	506 Stewart Ave	GARDEN CITY	NY	Active
DSH330259C	Child	DSH	MERCY MEDICAL CENTER	Partial Hospitalization	506 Stewart Ave	GARDEN CITY	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	PC Change Request	Kesicier, Anne-Marie Pharmacy Director Mercy Hospital 5167051053	Keiscier, AnneMarie Pharmacy director Catholic HEALTH 5167051053	8/28/2024 7:21 AM
Details	Last Recertification Date	Update	Recertification	8/26/2023 1:42:04 PM	8/28/2024 6:46:33 AM	8/28/2024 6:46 AM
Contacts	Authorizing Official	Update	AO Change Request	Morahan, John VP- Finance Mercy Medical Center 5167051317	Ibrahim, Ihab Chief Operating Officer/Director of Pharmacy Mercy Medical Center 5167056480	8/21/2024 1:02 PM
Contacts	Primary Contact	Update	Recertification	Ibrahim, Ihab Chief Operating Officer/Director of Pharmacy Mercy Medical Center 5167056480	Kesicier, Anne-Marie Pharmacy Director Mercy Hospital 5167051053	8/26/2023 1:42 PM
Details	Last Recertification Date	Update	Recertification	9/14/2022 9:55:55 AM	8/26/2023 1:42:04 PM	8/26/2023 1:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4161106	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		008041851	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		091257300	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0017745260001	1/12/2023 3:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1659330173	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427017854	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598724924	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427017854	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598724924	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1659330173	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427017854	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598724924	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1659330173	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427017854	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598724924	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	1/12/2023 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1659330173	1/12/2023 3:33 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	1/12/2023 3:33 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 10:39:49 AM	9/14/2022 9:55:55 AM	9/14/2022 9:55 AM
Contacts	Primary Contact	Update	Change Request	Macchia, Mark Director of Pharmacy Mercy Medical Center 5167051052	Ibrahim, Ihab Chief Operating Officer/Director of Pharmacy Mercy Medical Center 5167056480	11/3/2021 8:52 AM
Details	Last Recertification Date	Update	Recertification	8/18/2020 3:03:42 PM	8/17/2021 10:39:49 AM	8/17/2021 10:39 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1427017854	8/18/2020 3:03 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/18/2020 3:03 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1598724924	8/18/2020 3:03 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/18/2020 3:03 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1659330173	8/18/2020 3:03 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/18/2020 3:03 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1659330173 ( )		8/18/2020 3:03 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1427017854 ( )		8/18/2020 3:03 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1598724924 ( )		8/18/2020 3:03 PM
Details	Last Recertification Date	Update	Recertification	9/15/2019 1:34:25 PM	8/18/2020 3:03:42 PM	8/18/2020 3:03 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 2:21:17 PM	9/15/2019 1:34:25 PM	9/15/2019 1:34 PM
Contacts	Authorizing Official	Update	Change Request	Beine, Janine VP of Finance Mercy Medical Center 5167051317	Morahan, John VP- Finance Mercy Medical Center 5167051317	4/10/2019 11:06 AM
Contacts	Primary Contact	Update	Change Request	Lun, Wing Director of Pharmacy Mercy Medical Center 5167051051	Macchia, Mark Director of Pharmacy Mercy Medical Center 5167051052	2/7/2019 3:12 PM
Addresses	Shipping Address	Insert	Change Request		Safecor Health 317 New Boston Street Suite #100 Woburn, MA 01801	9/28/2018 8:19 AM
Details	Last Recertification Date	Update	Recertification	11/21/2017 11:51:22 AM	8/22/2018 2:21:17 PM	8/22/2018 2:21 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/21/2017 11:51:22 AM	11/21/2017 11:51 AM
Contacts	Primary Contact	Update	Recertification	Lun, Wing Director of Pharmacy 5167051051	Lun, Wing Director of Pharmacy Mercy Medical Center 5167051051	11/21/2017 10:31 AM
Contacts	Authorizing Official	Update		Beine, Janine VP of Finance 5167051317	Beine, Janine VP of Finance Mercy Medical Center 5167051317	11/16/2017 2:21 PM
Contacts	Signed By	Update		Beine, Janine VP of Finance 5167051317	Beine, Janine VP of Finance Mercy Medical Center 5167051317	11/16/2017 2:21 PM
Addresses	Main Address	Insert			1000 NORTH VILLAGE AVE ROCKVILLE CENTRE, NY 11570	6/30/2017 6:34 PM
Contacts	Authorizing Official	Insert			Beine, Janine VP of Finance 5167051317	6/30/2017 6:34 PM
Contacts	Signed By	Insert			Beine, Janine VP of Finance 5167051317	6/30/2017 6:34 PM
Contacts	Primary Contact	Insert			Lun, Wing Director of Pharmacy 5167051051	6/30/2017 6:34 PM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 12:29 PM
Dates	Participating Approval Date	Update			11/5/2015 12:00:00 AM	11/5/2015 12:20 PM
Details	State	Update		Pending	Active	11/5/2015 12:20 PM
Dates	Start Date	Update			1/1/2016 12:00:00 AM	11/5/2015 12:20 PM
Details	340B ID	Update		ONLINE_REG_54877	DSH330259	10/14/2015 10:16 AM
Details	340B ID	Update			ONLINE_REG_54877	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: Number	Insert			02996725	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: State	Insert			NY	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: Number	Insert			02969111	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: State	Insert			NY	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: Number	Insert			02969102	10/9/2015 11:46 AM
Medicaid Billing	Medicaid: State	Insert			NY	10/9/2015 11:46 AM
Medicaid Billing	NPI: Number	Insert			1659330173	10/9/2015 11:46 AM
Medicaid Billing	NPI: Number	Insert			1427017854	10/9/2015 11:46 AM
Medicaid Billing	NPI: Number	Insert			1598724924	10/9/2015 11:46 AM
Details	Last Recertification Date	Insert				10/9/2015 11:46 AM
Details	Grant Number	Insert				10/9/2015 11:46 AM
Details	340B ID	Insert				10/9/2015 11:46 AM
Details	Is Authorizing Official EHB Data	Insert				10/9/2015 11:46 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/9/2015 11:46 AM
Details	Medicare Provider Number	Insert			330259	10/9/2015 11:46 AM
Details	Entity Name	Insert			MERCY MEDICAL CENTER	10/9/2015 11:46 AM
Details	Program Code	Insert			DSH	10/9/2015 11:46 AM
Details	Entity Subname	Insert				10/9/2015 11:46 AM
Dates	Participating Approval Date	Insert				10/9/2015 11:46 AM
Details	State	Insert			Pending	10/9/2015 11:46 AM
Dates	Registration Date	Insert			10/9/2015 12:00:00 AM	10/9/2015 11:46 AM
Dates	Signed By Date	Insert			10/9/2015 12:00:00 AM	10/9/2015 11:46 AM
Dates	Start Date	Insert				10/9/2015 11:46 AM
Terminations	Termination Comments	Insert				10/9/2015 11:46 AM
Terminations	Termination Date	Insert				10/9/2015 11:46 AM
Terminations	Termination Effective Date	Insert				10/9/2015 11:46 AM
Terminations	Termination Reason	Insert				10/9/2015 11:46 AM