Covered Entity Details

SCH330157-16 SAMARITAN MEDICAL CENTER (Terminated) - information as of 5/3/2025 11:31:49 PM

Main Details

Name

SAMARITAN MEDICAL CENTER

Subdivision Name

SAMARITAN MEDICAL CENTER - Samaritan Health Dermatology Clinic

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH330157-16

Medicare Provider Number

330157

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/11/2017

Participating Start Date

1/1/2018

Participating Approval Date

11/21/2017

Last Recertification Date

8/22/2019

Termination Date
Termination Reason

10/1/2020
Change of covered entity type

Contacts

Authorizing Official

Samaritan Medical Center
Maxine A Briggs, VP Of Fiscal Services/Chief Financial Officer
(315) 755-3605

Primary Contact

Samaritan Medical Center
Krista Ann Krull-Goss, Director of Pharmacy
(315) 785-4248

Addresses

Street Address

830 WASHINGTON STREET
WATERTOWN, NY 13601-9367

Billing Address

Samaritan Health Dermatology Clinic
830 Washington Street
Watertown, NY 13601

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
NY	03001594,00354316,03001609
		1598713745,1093722068,1801902713

Shipping Addresses

Shipping Address 1

Samaritan Health Dermatology Clinic
830 Washington Street
Watertown, NY 13601

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
SCH330157-01	Child	SCH	SAMARITAN MEDICAL CENTER	Pain Clinic	830 Washington Street	Watertown	NY	Terminated
SCH330157-02	Child	SCH	SAMARITAN MEDICAL CENTER	A Women's Perspective OB/GYN Clinic	22567 Summit Drive., Bldg 2, Ste. C	Watertown	NY	Terminated
SCH330157-03	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Wound Care Clinic	165 COLEMAN AVE	WATERTOWN	NY	Terminated
SCH330157-04	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FAMILY HEALTH CENTER - Samaritan Health Sackets Harbor Clinic	105 BARRACKS DR	SACKETS HARBOR	NY	Terminated
SCH330157-05	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health LaCona Clinic	3 DEMOTT ST	LACONA	NY	Terminated
SCH330157-06	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Clayton Clinic	909 STRAWBERRY LANE	CLAYTON	NY	Terminated
SCH330157-07	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FAMILY HEALTH CENTER - Samaritan Health Adams Clinic	10881 US ROUTE 11	ADAMS	NY	Terminated
SCH330157-08	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Washington Street Plaza Clinic	1575 WASHINGTON ST	WATERTOWN	NY	Terminated
SCH330157-09	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FAMILY HEALTH CENTER - Samaritan Health Urology Clinic	22567 SUMMIT DRIVE	WATERTOWN	NY	Terminated
SCH330157-10	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN URGENT CARE - Samaritan Health LeRay Urgent Care	26908 INDEPENDENCE WAY	EVANS MILLS	NY	Terminated
SCH330157-11	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - SMC Alcohol/Chemical Dependency Clinic	1575 WASHINGTON ST	WATERTOWN	NY	Terminated
SCH330157-12	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Behavioral Health Clinic	1575 WASHINGTON ST	WATERTOWN	NY	Terminated
SCH330157-13	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FAMILY HEALTH CENTER - Samaritan Health LeRay Clinic	26908 Independence Way	EVANS MILLS	NY	Terminated
SCH330157-14	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - WOMEN'S WELLNESS & BREAST CARE	1575 WASHINGTON ST	WATERTOWN	NY	Terminated
SCH330157-15	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN FMAILY HEALTH CENTER - Samaritan Health Cape Vincent Clinic	782 EAST BROADWAY ST	CAPE VINCENT	NY	Terminated
SCH330157-16	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Dermatology Clinic	830 WASHINGTON STREET	WATERTOWN	NY	Terminated
SCH330157-17	Child	SCH	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - RHEUMATOLOGY - RHEUMATOLOGY	629 WASHINGTON STREET	WATERTOWN	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	7/16/2020 12:41 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	7/16/2020 12:41 PM
Terminations	Termination Date	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	7/16/2020 12:41 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	7/16/2020 12:41 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	7/16/2020 12:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2020 9:17 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03001594	3/21/2020 9:17 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	3/21/2020 9:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2020 9:17 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00354316	3/21/2020 9:17 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	3/21/2020 9:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2020 9:17 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		03001609	3/21/2020 9:17 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	3/21/2020 9:17 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1598713745	3/21/2020 9:17 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1093722068	3/21/2020 9:17 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1801902713	3/21/2020 9:17 AM
Contacts	Authorizing Official	Update	AO Change Request	Carman, Thomas H. President & CEO Samaritan Medical Center 3157854121	Briggs, Maxine A VP Of Fiscal Services/Chief Financial Officer Samaritan Medical Center 3157553605	1/30/2020 8:22 AM
Addresses	Main Address	Update	Change Request	1575 WASHINGTON ST WATERTOWN, NY 13601-9367	830 WASHINGTON STREET WATERTOWN, NY 13601-9367	1/8/2020 10:54 AM
Details	Last Recertification Date	Update	Recertification	8/18/2018 8:22:03 AM	8/22/2019 9:52:22 AM	8/22/2019 9:52 AM
Contacts	Primary Contact	Update	Profile Change Request	Krull-Goss, Krista Ann Assistant Director of Pharmacy Samaritan Medical Center 3157854248	Krull-Goss, Krista Ann Director of Pharmacy Samaritan Medical Center 3157854248	3/15/2019 2:15 PM
Details	Last Recertification Date	Update	Recertification		8/18/2018 8:22:03 AM	8/18/2018 8:22 AM
Contacts	Primary Contact	Update	Change Request	Sanzone, Joseph Director of Pharmacy Samaritan Medical Center 3157854293	Krull-Goss, Krista Ann Assistant Director of Pharmacy Samaritan Medical Center 3157854248	7/30/2018 2:49 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Carman, Thomas H. President & CEO Samaritan Medical Center 3157854121	11/21/2017 9:23 AM
Details	340B ID	Update	New Registration		SCH330157-16	11/21/2017 9:23 AM
Details	Entity Subname	Update	New Registration	SAMARITAN MEDICAL CENTER	SAMARITAN MEDICAL CENTER - Samaritan Health Dermatology Clinic	11/21/2017 9:23 AM
Dates	Participating Approval Date	Update	New Registration		11/21/2017 9:23:49 AM	11/21/2017 9:23 AM
Details	State	Update	New Registration	Pending	Approved	11/21/2017 9:23 AM
Dates	Signed By Date	Update	New Registration		11/20/2017 3:45:37 PM	11/21/2017 9:23 AM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	11/21/2017 9:23 AM
Addresses	Main Address	Insert	New Registration		1575 WASHINGTON ST WATERTOWN, NY 13601-9367	10/11/2017 10:28 AM
Addresses	Billing Address	Insert	New Registration		Samaritan Health Dermatology Clinic 830 Washington Street Watertown, NY 13601	10/11/2017 10:28 AM
Addresses	Shipping Address	Insert	New Registration		Samaritan Health Dermatology Clinic 830 Washington Street Watertown, NY 13601	10/11/2017 10:28 AM
Contacts	Primary Contact	Insert	New Registration		Sanzone, Joseph Director of Pharmacy Samaritan Medical Center 3157854293	10/11/2017 10:28 AM
Contacts	Authorizing Official	Insert	New Registration		Carman, Thomas H. President & CEO Samaritan Medical Center 3157854121	10/11/2017 10:28 AM
Details	Last Recertification Date	Insert	New Registration			10/11/2017 10:28 AM
Details	Grant Number	Insert	New Registration			10/11/2017 10:28 AM
Details	340B ID	Insert	New Registration			10/11/2017 10:28 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2017 10:28 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2017 10:28 AM
Details	Medicare Provider Number	Insert	New Registration		330157	10/11/2017 10:28 AM
Details	Entity Name	Insert	New Registration		SAMARITAN MEDICAL CENTER	10/11/2017 10:28 AM
Details	Program Code	Insert	New Registration		SCH	10/11/2017 10:28 AM
Details	Entity Subname	Insert	New Registration		SAMARITAN MEDICAL CENTER	10/11/2017 10:28 AM
Dates	Participating Approval Date	Insert	New Registration			10/11/2017 10:28 AM
Details	State	Insert	New Registration		Pending	10/11/2017 10:28 AM
Dates	Registration Date	Insert	New Registration		10/11/2017 10:28:21 AM	10/11/2017 10:28 AM
Dates	Signed By Date	Insert	New Registration			10/11/2017 10:28 AM
Dates	Start Date	Insert	New Registration			10/11/2017 10:28 AM
Terminations	Termination Comments	Insert	New Registration			10/11/2017 10:28 AM
Terminations	Termination Date	Insert	New Registration			10/11/2017 10:28 AM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2017 10:28 AM
Terminations	Termination Reason	Insert	New Registration			10/11/2017 10:28 AM