Covered Entity Details

DSH070016F Saint Mary's Hospital (Terminated) - information as of 6/24/2025 12:01:29 AM

Main Details

Name

Saint Mary's Hospital

Subdivision Name

West Main Street Urgent Care

Type

Disproportionate Share Hospital

Rural

340B ID

DSH070016F

Medicare Provider Number

070016

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/11/2017

Participating Start Date

4/1/2017

Participating Approval Date

3/2/2017

Last Recertification Date

9/8/2020

Termination Date
Termination Reason

4/1/2021
Change of covered entity type (non-hospital)

Contacts

Authorizing Official

Saint Mary's Hospital
Chris M Hayes, VP of Finance
(203) 709-6294

Primary Contact

Saint Francis Hospital and Medical Center
James M Harris, Regional Director of Reimbursement
(860) 714-4396

Addresses

Street Address

1312 West Main Street
Waterbury, CT 06708

Billing Address

Saint Mary's Hospital
56 Franklin Street
Waterbury, CT 06706

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	004041760,004025060	1760426969
ID	1760426969	1760426969
ME	1760426969	1760426969
MA	110027739A,110027739B	1760426969
NY	00350909	1760426969
WI	1760426969	1760426969
WA	1060544	1760426969

Shipping Addresses

Shipping Address 1

Saint Mary's Hospital
56 Franklin Street
Waterbury, CT 06706

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
DSH070016A	Child	DSH	Saint Mary's Hospital	Naugatuck Valley Surgical Center	160 Robbins Street	Waterbury	CT	Active
DSH070016B	Child	DSH	Saint Mary's Hospital	Saint Mary's Urgent Care Center - Naugatuck	58 Maple St	Naugatuck	CT	Terminated
DSH070016C	Child	DSH	Saint Mary's Hospital	Saint Mary's Urgent Care Center - Wolcott	503 Wolcott Road	Wolcott	CT	Terminated
DSH070016D	Child	DSH	Saint Mary's Hospital	Outpatient Behavorial Health	100 Jefferson Square	Waterbury	CT	Terminated
DSH070016E	Child	DSH	Saint Mary's Hospital	Chase Oncology Infusion Center	1075 Chase Pkwy	Waterbury	CT	Active
DSH070016F	Child	DSH	Saint Mary's Hospital	West Main Street Urgent Care	1312 West Main Street	Waterbury	CT	Terminated
DSH070016G	Child	DSH	Saint Mary's Hospital	Saint Mary's Urgent Care Center - Cheshire	1154 Highland Avenue	Cheshire	CT	Terminated
DSH070016H	Child	DSH	Saint Mary's Hospital	Saint Mary's Urgent Care Center - East Main	3801 East Main Street	Waterbury	CT	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		1/28/2021 12:00:00 AM	2/11/2021 9:43 AM
Details	State	Update	Termination Request	Active	To Be Terminated	2/11/2021 9:43 AM
Terminations	Termination Comments	Update	Termination Request		Change of ownership to Premier Urgent Care	2/11/2021 9:43 AM
Terminations	Termination Date	Update	Termination Request		4/1/2021 12:00:00 AM	2/11/2021 9:43 AM
Terminations	Termination Effective Date	Update	Termination Request		1/29/2021 12:00:00 AM	2/11/2021 9:43 AM
Terminations	Termination Reason	Update	Termination Request		Change of covered entity type (non-hospital)	2/11/2021 9:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		004041760	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110027739A	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110027739B	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00350909	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1060544	9/8/2020 2:00 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	9/8/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/8/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/8/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/8/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/8/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/8/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 2:00 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1760426969	9/8/2020 2:00 PM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/8/2020 2:00 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1760426969 ( )		9/8/2020 2:00 PM
Contacts	Primary Contact	Update	Recertification	Welti, Dean R Interim Manager of Third Party Saint Mary's Hospital 2037093166	Harris, James M Regional Director of Reimbursement Saint Francis Hospital and Medical Center 8607144396	9/8/2020 2:00 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 4:03:41 PM	9/8/2020 2:00:59 PM	9/8/2020 2:00 PM
Contacts	Primary Contact	Update	Change Request	Welti, Dean Interim Manager of Reimbursement Saint Mary's Hospital 2037093166	Welti, Dean R Interim Manager of Third Party Saint Mary's Hospital 2037093166	10/30/2019 8:29 AM
Contacts	Authorizing Official	Update	AO Change Request	Hayes, Chris VP Finance Saint Mary's Hospital 2037096294	Hayes, Chris M VP of Finance Saint Mary's Hospital 2037096294	9/30/2019 10:45 AM
Contacts	Primary Contact	Update	Profile Change Request	Welti, Dean Interim Director of Reimbursement Saint Mary's Hospital 2037093166	Welti, Dean Interim Manager of Reimbursement Saint Mary's Hospital 2037093166	9/24/2019 9:32 AM
Details	Last Recertification Date	Update	Recertification	8/24/2018 4:00:01 PM	8/20/2019 4:03:41 PM	8/20/2019 4:03 PM
Contacts	Authorizing Official	Update	Change Request	Novak, Michael Vice President of Administration and CIO Saint Mary's Hospital 2037093508	Hayes, Chris VP Finance Saint Mary's Hospital 2037096294	1/30/2019 4:17 PM
Details	Entity Name	Update	Change Request	ST. MARYS HOSPITAL	Saint Mary's Hospital	1/30/2019 4:17 PM
Contacts	Primary Contact	Update	Profile Change Request	Welti, Dean Interim Director of Reimbursement 070016 2037093166	Welti, Dean Interim Director of Reimbursement Saint Mary's Hospital 2037093166	1/8/2019 2:25 PM
Addresses	Billing Address	Insert	Recertification		Saint Mary's Hospital 56 Franklin Street Waterbury, CT 06706	8/24/2018 4:00 PM
Addresses	Shipping Address	Insert	Recertification		Saint Mary's Hospital 56 Franklin Street Waterbury, CT 06706	8/24/2018 4:00 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 2:18:06 PM	8/24/2018 4:00:01 PM	8/24/2018 4:00 PM
Details	Last Recertification Date	Update	Recertification		11/8/2017 2:18:06 PM	11/8/2017 2:18 PM
Contacts	Primary Contact	Update		Welti, Dean Interim Director of Reimbursement 2037093166	Welti, Dean Interim Director of Reimbursement 070016 2037093166	11/7/2017 9:55 AM
Contacts	Authorizing Official	Update		Novak, Michael Vice President of Administration and CIO 2037093508	Novak, Michael Vice President of Administration and CIO Saint Mary's Hospital 2037093508	10/30/2017 11:20 AM
Contacts	Authorizing Official	Insert			Novak, Michael Vice President of Administration and CIO 2037093508	6/19/2017 3:23 PM
Contacts	Signed By	Insert			Becker, Ralph CFO 2037095871	6/19/2017 3:23 PM
Contacts	Primary Contact	Insert			Welti, Dean Interim Director of Reimbursement 2037093166	6/19/2017 3:23 PM
Addresses	Main Address	Insert			1312 West Main Street Waterbury, CT 06708	6/19/2017 3:22 PM
Dates	Participating Approval Date	Update			3/2/2017 12:00:00 AM	3/2/2017 5:39 PM
Details	State	Update		Pending	Active	3/2/2017 5:39 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	3/2/2017 5:39 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_74504	DSH070016F	1/19/2017 10:50 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_74504	1/11/2017 12:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/11/2017 12:03 PM
Medicaid Billing	Medicaid: Number	Insert			004025060	1/11/2017 12:03 PM
Medicaid Billing	Medicaid: State	Insert			CT	1/11/2017 12:03 PM
Medicaid Billing	NPI: Number	Insert			1760426969	1/11/2017 12:03 PM
Details	Last Recertification Date	Insert				1/11/2017 12:03 PM
Details	Grant Number	Insert				1/11/2017 12:03 PM
Details	340B ID	Insert				1/11/2017 12:03 PM
Details	Is Authorizing Official EHB Data	Insert				1/11/2017 12:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/11/2017 12:03 PM
Details	Medicare Provider Number	Insert			070016	1/11/2017 12:03 PM
Details	Entity Name	Insert			ST. MARYS HOSPITAL	1/11/2017 12:03 PM
Details	Program Code	Insert			DSH	1/11/2017 12:03 PM
Details	Entity Subname	Insert			West Main Street Urgent Care	1/11/2017 12:03 PM
Dates	Participating Approval Date	Insert				1/11/2017 12:03 PM
Details	State	Insert			Pending	1/11/2017 12:03 PM
Dates	Registration Date	Insert			1/11/2017 12:00:00 AM	1/11/2017 12:03 PM
Dates	Signed By Date	Insert			1/11/2017 12:00:00 AM	1/11/2017 12:03 PM
Dates	Start Date	Insert				1/11/2017 12:03 PM
Terminations	Termination Comments	Insert				1/11/2017 12:03 PM
Terminations	Termination Date	Insert				1/11/2017 12:03 PM
Terminations	Termination Effective Date	Insert				1/11/2017 12:03 PM
Terminations	Termination Reason	Insert				1/11/2017 12:03 PM