Covered Entity Details

RRC330103-23 Olean General Hospital (Terminated) - information as of 5/20/2025 12:50:40 AM

Main Details

Name

Olean General Hospital

Subdivision Name

BRMC - Mt Jewett Health Center

Type

Rural Referral Center

Rural

Yes

340B ID

RRC330103-23

Medicare Provider Number

330103

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/12/2018

Participating Start Date

4/1/2018

Participating Approval Date

2/1/2018

Last Recertification Date

8/20/2018

Termination Date
Termination Reason

10/1/2019
Change of covered entity type

Contacts

Authorizing Official

Bradford Regional Medical Center
Richard G. Braun Jr., SVP Finance and CFO
(716) 375-6190

Primary Contact

Olean General Hospital
Victoria Nosowicz, Pharmacy Informatics & 340B Manager
(716) 375-6268

Addresses

Street Address

122 W Main St
Mt Jewett, PA 16740

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
PA	1007755030038
		1245502905

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
RRC330103-01	Child	RRC	Olean General Hospital	General Medical	4039 RT. 219	SALAMANCA	NY	Terminated
RRC330103-02	Child	RRC	Olean General Hospital	OLEAN GENERAL HOSPITAL / Gastroenterology	2666 WEST STATE STREET	OLEAN	NY	Terminated
RRC330103-03	Child	RRC	Olean General Hospital	OLEAN GENERAL HOSPITAL / Wound	623 MAIN ST	OLEAN	NY	Terminated
RRC330103-04	Child	RRC	Olean General Hospital	OLEAN GENERAL HOSPITAL / Urology	623 MAIN ST	OLEAN	NY	Terminated
RRC330103-05	Child	RRC	Olean General Hospital	OLEAN GENERAL HOSPITAL / Family Medicine	2666 WEST STATE STREET	OLEAN	NY	Terminated
RRC330103-06	Child	RRC	Olean General Hospital	OLEAN GENERAL HOSPITAL / General surgery	2666 WEST STATE STREET	OLEAN	NY	Terminated
RRC330103-07	Child	RRC	Olean General Hospital	OLEAN GENERAL HOSPITAL / Dialysis	623 MAIN ST	OLEAN	NY	Terminated
RRC330103-08	Child	RRC	Olean General Hospital	Primary Care	38N MAIN ST	DELEVAN	NY	Terminated
RRC330103-09	Child	RRC	Olean General Hospital	Oncology	528 NORTH BARRY STREET	OLEAN	NY	Terminated
RRC330103-10	Child	RRC	Olean General Hospital	Ambulatory Surgery Center	500 MAIN ST	OLEAN	NY	Terminated
RRC330103-11	Child	RRC	Olean General Hospital	BRMC - Same Day Ambulatory	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-12	Child	RRC	Olean General Hospital	BRMC - Smethport Health Center	406 Franklin St	Smethport	PA	Terminated
RRC330103-13	Child	RRC	Olean General Hospital	BRMC - Bradford Family Medicine	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-14	Child	RRC	Olean General Hospital	BRMC - Pediatric Clinic	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-15	Child	RRC	Olean General Hospital	BRMC - Same Day Surgery	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-16	Child	RRC	Olean General Hospital	BRMC - Psych Ambulatory	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-17	Child	RRC	Olean General Hospital	BRMC - Women's Health Center	159 Interstate Parkway	Bradford	PA	Terminated
RRC330103-18	Child	RRC	Olean General Hospital	BRMC - Operating Room	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-19	Child	RRC	Olean General Hospital	BRMC - Chemo	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-20	Child	RRC	Olean General Hospital	BRMC - Orthopaedics	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-21	Child	RRC	Olean General Hospital	BRMC - Respiratory Therapy	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-22	Child	RRC	Olean General Hospital	BRMC - General Surgery	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-23	Child	RRC	Olean General Hospital	BRMC - Mt Jewett Health Center	122 W Main St	Mt Jewett	PA	Terminated
RRC330103-24	Child	RRC	Olean General Hospital	BRMC - OB Outpatient	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-25	Child	RRC	Olean General Hospital	BRMC - Ambulatory Care	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-26	Child	RRC	Olean General Hospital	BRMC - Pain Mgt	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-27	Child	RRC	Olean General Hospital	BRMC - Emergency Room	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-28	Child	RRC	Olean General Hospital	BRMC - 3 North Ambulatory Infusions	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-29	Child	RRC	Olean General Hospital	BRMC - 3 South Observation Patients	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-30	Child	RRC	Olean General Hospital	BRMC - 3 East Observation Patients	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-31	Child	RRC	Olean General Hospital	BRMC - 4 East Observation Patients	116 Interstate Parkway	Bradford	PA	Terminated
RRC330103-32	Child	RRC	Olean General Hospital	BRMC-PULMONARY FUNCTION - RESPIRATORY	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-33	Child	RRC	Olean General Hospital	BRMC-OBSTETRICS/GYN UNIT OUTPATIENTS - OB	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-34	Child	RRC	Olean General Hospital	BRMC-MAMOGRAPHY - XRAY	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-35	Child	RRC	Olean General Hospital	BRMC-RADIOLOGY - RADIOLOGY	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-36	Child	RRC	Olean General Hospital	BRMC-COMPUTERIZED TOMOGRAPHY - CT	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-37	Child	RRC	Olean General Hospital	BRMC-ULTRASOUND - DIAGNOSTIC IMAGING	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-38	Child	RRC	Olean General Hospital	BRMC-ER OVERFLO OBSERVATION PATIENTS - ER	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-39	Child	RRC	Olean General Hospital	BRMC-NUCLEAR MEDICINE - DIAGNOSTIC IMAGING	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-40	Child	RRC	Olean General Hospital	BRMC-MRI - XRAY	116 INTERSTATE PKWY	BRADFORD	PA	Terminated
RRC330103-41	Child	RRC	Olean General Hospital	BRMC-CRITICAL CARE UNIT OBSERVATION PATIENTS - CCU	116 INTERSTATE PKWY	BRADFORD	PA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		10/1/2019 12:00:00 AM	8/15/2019 10:46 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	8/15/2019 10:46 AM
Terminations	Termination Date	Update	Hospital Type Change Request		10/1/2019 12:00:00 AM	8/15/2019 10:46 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		10/1/2019 12:00:00 AM	8/15/2019 10:46 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	8/15/2019 10:46 AM
Contacts	Primary Contact	Update	Profile Change Request	Nosowicz, Victoria Pharmacy Informatics & 340B Manager Bradford Regional Medical Center 7163756268	Nosowicz, Victoria Pharmacy Informatics & 340B Manager Olean General Hospital 7163756268	3/5/2019 9:21 AM
Contacts	Primary Contact	Update	Profile Change Request	Nosowicz, Victoria Pharmacy Informatics / 340B Manager Bradford Regional Medical Center 7163756268	Nosowicz, Victoria Pharmacy Informatics & 340B Manager Bradford Regional Medical Center 7163756268	1/10/2019 1:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/15/2018 3:19 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007755030038	10/15/2018 3:19 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	10/15/2018 3:19 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1245502905	10/15/2018 3:19 PM
Contacts	Primary Contact	Update	Change Request	KREINER, TOM PHARMACY MANGER Bradford Regional Medical Center 8143628222	Nosowicz, Victoria Pharmacy Informatics / 340B Manager Bradford Regional Medical Center 7163756268	10/15/2018 3:19 PM
Details	Last Recertification Date	Update	Recertification		8/20/2018 8:40:37 AM	8/20/2018 8:40 AM
Details	State	Update		Approved	Active	4/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Braun Jr., Richard G. SVP Finance and CFO Bradford Regional Medical Center 7163756190	2/1/2018 12:48 PM
Details	340B ID	Update	New Registration		RRC330103-23	2/1/2018 12:48 PM
Details	Entity Subname	Update	New Registration	BRMC	BRMC - Mt Jewett Health Center	2/1/2018 12:48 PM
Dates	Participating Approval Date	Update	New Registration		2/1/2018 12:48:20 PM	2/1/2018 12:48 PM
Details	State	Update	New Registration	Pending	Approved	2/1/2018 12:48 PM
Dates	Signed By Date	Update	New Registration		1/12/2018 9:40:31 AM	2/1/2018 12:48 PM
Dates	Start Date	Update	New Registration		4/1/2018 12:00:00 AM	2/1/2018 12:48 PM
Addresses	Main Address	Insert	New Registration		122 W Main St Mt Jewett, PA 16740	1/12/2018 9:40 AM
Contacts	Authorizing Official	Insert	New Registration		Braun Jr., Richard G. SVP Finance and CFO Bradford Regional Medical Center 7163756190	1/12/2018 9:40 AM
Contacts	Primary Contact	Insert	New Registration		KREINER, TOM PHARMACY MANGER Bradford Regional Medical Center 8143628222	1/12/2018 9:40 AM
Details	Last Recertification Date	Insert	New Registration			1/12/2018 9:40 AM
Details	Grant Number	Insert	New Registration			1/12/2018 9:40 AM
Details	340B ID	Insert	New Registration			1/12/2018 9:40 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/12/2018 9:40 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/12/2018 9:40 AM
Details	Medicare Provider Number	Insert	New Registration		330103	1/12/2018 9:40 AM
Details	Entity Name	Insert	New Registration		Olean General Hospital	1/12/2018 9:40 AM
Details	Program Code	Insert	New Registration		RRC	1/12/2018 9:40 AM
Details	Entity Subname	Insert	New Registration		BRMC	1/12/2018 9:40 AM
Dates	Participating Approval Date	Insert	New Registration			1/12/2018 9:40 AM
Details	State	Insert	New Registration		Pending	1/12/2018 9:40 AM
Dates	Registration Date	Insert	New Registration		1/12/2018 9:40:29 AM	1/12/2018 9:40 AM
Dates	Signed By Date	Insert	New Registration			1/12/2018 9:40 AM
Dates	Start Date	Insert	New Registration			1/12/2018 9:40 AM
Terminations	Termination Comments	Insert	New Registration			1/12/2018 9:40 AM
Terminations	Termination Date	Insert	New Registration			1/12/2018 9:40 AM
Terminations	Termination Effective Date	Insert	New Registration			1/12/2018 9:40 AM
Terminations	Termination Reason	Insert	New Registration			1/12/2018 9:40 AM