Covered Entity Details

DSH220063D THE LOWELL GENERAL HOSPITAL (Active) - information as of 5/16/2025 11:34:20 PM

Main Details

Name

THE LOWELL GENERAL HOSPITAL

Subdivision Name

Saints Campus / TB/Immunization Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220063D

Medicare Provider Number

220063

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2016

Participating Start Date

10/1/2016

Participating Approval Date

9/14/2016

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Tufts Medicine Lowell General Hospital
Keary Allicon, Sr. Director of Finance
(978) 937-6353

Primary Contact

Lowell General
Eric Musial, Director of Pharmacy Services
(978) 937-6416

Addresses

Street Address

1 Hospital Drive
Lowell, MA 01852

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
CT	003023918	1407804669
NY	01546941	1407804669
VT	0220063	1407804669
CA	1407804669	1407804669
ME	1407804669	1407804669
NC	1407804669	1407804669
NH	3071539	1407804669
FL	901289300	1407804669
MA	110026472	1407804669

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
DSH220063A	Child	DSH	THE LOWELL GENERAL HOSPITAL	THE SURGERY CENTER AT DRUM HILL	10 RESEARCH PLACE	NORTH CHELMSFORD	MA	Terminated
DSH220063B	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Radiology	1 Hosptial Drive	Lowell	MA	Active
DSH220063C	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Interventional Radiology	1 Hospital Drive	Lowell	MA	Active
DSH220063D	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / TB/Immunization Clinic	1 Hospital Drive	Lowell	MA	Active
DSH220063E	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Adults & Peds Observation	1 Hospital Drive	Lowell	MA	Active
DSH220063F	Child	DSH	THE LOWELL GENERAL HOSPITAL	THE LOWELL GENERAL HOSPITAL	1230 BRIDGE ST	LOWELL	MA	Terminated
DSH220063G	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / ALS	1 Hospital Drive	Lowell	MA	Active
DSH220063H	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Surgical Day Care	1 Hospital Drive	Lowell	MA	Active
DSH220063J	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Endoscopy	1 Hospital Drive	Lowell	MA	Active
DSH220063K	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Medical Day Care Clinic	1 Hospital Drive	Lowell	MA	Active
DSH220063L	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Anesthesia	1 Hospital Drive	Lowell	MA	Active
DSH220063M	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / PACU	1 Hospital Drive	Lowell	MA	Active
DSH220063N	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Operating Rooms	1 Hospital Drive	Lowell	MA	Terminated
DSH220063P	Child	DSH	THE LOWELL GENERAL HOSPITAL	Saints Campus / Emergency Department	1 Hospital Drive	Lowell	MA	Active
DSH220063Q	Child	DSH	THE LOWELL GENERAL HOSPITAL	THE LOWELL GENERAL HOSPITAL / Pain Clinic	2 HOSPITAL DR 2	LOWELL	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 4:56:36 PM	9/3/2024 4:38:11 PM	9/3/2024 4:38 PM
Contacts	Authorizing Official	Update	AO Change Request	Wyman, William F SVP of Operations & Treasurer TuftsMedicine 9789376034	Allicon, Keary Sr. Director of Finance Tufts Medicine Lowell General Hospital 9789376353	8/26/2024 10:32 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 9:02:43 AM	8/23/2023 4:56:36 PM	8/23/2023 4:56 PM
Details	Last Recertification Date	Update	Recertification	8/19/2021 12:52:33 PM	8/30/2022 9:02:43 AM	8/30/2022 9:02 AM
Contacts	Authorizing Official	Update	Profile Change Request	Wyman, William F SVP of Finance & Treasurer Lowell General Hospial 9789376034	Wyman, William F SVP of Operations & Treasurer TuftsMedicine 9789376034	7/13/2022 6:31 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 9:57:10 AM	8/19/2021 12:52:33 PM	8/19/2021 12:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003023918	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		01546941	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0220063	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3071539	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NH	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		901289300	8/26/2020 9:57 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		VT	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		NH	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407804669	8/26/2020 9:57 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/26/2020 9:57 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1407804669 ( )		8/26/2020 9:57 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 8:54:30 PM	8/26/2020 9:57:10 AM	8/26/2020 9:57 AM
Details	Last Recertification Date	Update	Recertification	8/17/2018 7:49:12 AM	8/20/2019 8:54:30 PM	8/20/2019 8:54 PM
Contacts	Authorizing Official	Update	Profile Change Request	Wyman, William Vice President of Finance Lowell General Hospial 9789376034	Wyman, William F SVP of Finance & Treasurer Lowell General Hospial 9789376034	8/20/2019 8:49 PM
Details	Last Recertification Date	Update	Recertification	11/10/2017 12:38:13 PM	8/17/2018 7:49:12 AM	8/17/2018 7:49 AM
Contacts	Authorizing Official	Update	Change Request	Green, Susan Chief Financial Officer Lowell General Hospital 9787887143	Wyman, William Vice President of Finance Lowell General Hospial 9789376034	1/17/2018 7:37 AM
Details	Entity Name	Update	Recertification	LOWELL GENERAL HOSPITAL	THE LOWELL GENERAL HOSPITAL	11/15/2017 9:43 PM
Details	Last Recertification Date	Update	Recertification		11/10/2017 12:38:13 PM	11/10/2017 12:38 PM
Contacts	Authorizing Official	Update	AO Change Request	Green, Susan CFO 9789377143	Green, Susan Chief Financial Officer Lowell General Hospital 9787887143	11/7/2017 10:31 AM
Contacts	Primary Contact	Update		Musial, Eric Director of Pharmacy Services 9789376416	Musial, Eric Director of Pharmacy Services Lowell General 9789376416	11/6/2017 2:02 PM
Addresses	Main Address	Insert			1 Hospital Drive Lowell, MA 01852	9/14/2016 6:58 AM
Contacts	Primary Contact	Insert			Musial, Eric Director of Pharmacy Services 9789376416	9/14/2016 6:58 AM
Contacts	Authorizing Official	Insert			Green, Susan CFO 9789377143	9/14/2016 6:58 AM
Contacts	Signed By	Insert			Green, Susan CFO 9789377143	9/14/2016 6:58 AM
Dates	Participating Approval Date	Update			9/14/2016 12:00:00 AM	9/14/2016 6:55 AM
Details	State	Update		Pending	Active	9/14/2016 6:55 AM
Dates	Start Date	Update			10/1/2016 12:00:00 AM	9/14/2016 6:55 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_71309	DSH220063D	8/10/2016 1:05 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_71309	7/11/2016 10:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/11/2016 10:50 AM
Medicaid Billing	Medicaid: Number	Insert			110026472	7/11/2016 10:50 AM
Medicaid Billing	Medicaid: State	Insert			MA	7/11/2016 10:50 AM
Medicaid Billing	NPI: Number	Insert			1407804669	7/11/2016 10:50 AM
Details	Last Recertification Date	Insert				7/11/2016 10:50 AM
Details	Grant Number	Insert				7/11/2016 10:50 AM
Details	340B ID	Insert				7/11/2016 10:50 AM
Details	Is Authorizing Official EHB Data	Insert				7/11/2016 10:50 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/11/2016 10:50 AM
Details	Medicare Provider Number	Insert			220063	7/11/2016 10:50 AM
Details	Entity Name	Insert			LOWELL GENERAL HOSPITAL	7/11/2016 10:50 AM
Details	Program Code	Insert			DSH	7/11/2016 10:50 AM
Details	Entity Subname	Insert			Saints Campus / TB/Immunization Clinic	7/11/2016 10:50 AM
Dates	Participating Approval Date	Insert				7/11/2016 10:50 AM
Details	State	Insert			Pending	7/11/2016 10:50 AM
Dates	Registration Date	Insert			7/11/2016 12:00:00 AM	7/11/2016 10:50 AM
Dates	Signed By Date	Insert			7/11/2016 12:00:00 AM	7/11/2016 10:50 AM
Dates	Start Date	Insert				7/11/2016 10:50 AM
Terminations	Termination Comments	Insert				7/11/2016 10:50 AM
Terminations	Termination Date	Insert				7/11/2016 10:50 AM
Terminations	Termination Effective Date	Insert				7/11/2016 10:50 AM
Terminations	Termination Reason	Insert				7/11/2016 10:50 AM