Covered Entity Details

DSH390146D WARREN GENERAL HOSPITAL (Terminated) - information as of 5/9/2025 12:21:07 AM

Main Details

Name

WARREN GENERAL HOSPITAL

Subdivision Name

Youngsville Walk-In Care

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH390146D

Medicare Provider Number

390146

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/5/2018

Participating Start Date

1/1/2019

Participating Approval Date

10/23/2018

Last Recertification Date

8/21/2019

Termination Date
Termination Reason

10/1/2020
Site closure

Contacts

Authorizing Official

Warren General Hospital
Kathryn E. Carlson, Executive Director of Operations
(814) 723-4973 Ext: 1370

Primary Contact

Warren General Hospital
Damion M. Wise, Director of Pharmacy Services
(814) 723-3300 Ext: 1822

Addresses

Street Address

400 E. MAIN STREET
YOUNGSVILLE, PA 16371

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	1007234970038,1007284970027,1007284970021
		1659360220,1508803701

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
DSH390146A	Child	DSH	WARREN GENERAL HOSPITAL	Cancer Care Center	105 LEE ST	WARREN	PA	Active
DSH390146B	Child	DSH	WARREN GENERAL HOSPITAL	St. Clair General Surgery	103 ST CLAIR ST	WARREN	PA	Terminated
DSH390146C	Child	DSH	WARREN GENERAL HOSPITAL	Urology	2265 MARKET STREET EXTENSION	WARREN	PA	Active
DSH390146D	Child	DSH	WARREN GENERAL HOSPITAL	Youngsville Walk-In Care	400 E. MAIN STREET	YOUNGSVILLE	PA	Terminated
DSH390146E	Child	DSH	WARREN GENERAL HOSPITAL	Youngsville Family Practice	400 E. MAIN STREET	YOUNGSVILLE	PA	Active
DSH390146F	Child	DSH	WARREN GENERAL HOSPITAL	Radiation Oncology	105 LEE ST	WARREN	PA	Active
DSH390146G	Child	DSH	WARREN GENERAL HOSPITAL	St. Clair Family Practice	103 ST CLAIR ST	WARREN	PA	Active
DSH390146H	Child	DSH	WARREN GENERAL HOSPITAL	Pleasant Family Practice	143 PLEASANT DRIVE	WARREN	PA	Active
DSH390146J	Child	DSH	WARREN GENERAL HOSPITAL	Sugar Grove Family Practice	15 FOREST STREET	SUGAR GROVE	PA	Active

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	Termination Request		2/20/2020 12:00:00 AM	7/17/2020 11:54 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/17/2020 11:54 AM
Terminations	Termination Date	Update	Termination Request		10/1/2020 12:00:00 AM	7/17/2020 11:54 AM
Terminations	Termination Effective Date	Update	Termination Request		6/1/2020 12:00:00 AM	7/17/2020 11:54 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	7/17/2020 11:54 AM
Details	Entity Subname	Update	Change Request	WMG Youngsville Walk-In Care	Youngsville Walk-In Care	4/13/2020 2:25 PM
Contacts	Authorizing Official	Update	Change Request	Longo, Louis Chief Financial Officer Warren General Hospital 8145732211-2308	Carlson, Kathryn E. Executive Director of Operations Warren General Hospital 8147234973-1370	4/6/2020 3:35 PM
Contacts	Primary Contact	Update	Change Request	Wise, Damion Director of Pharmacy Services Warren General Hospital 8147233300-1822	Wise, Damion M. Director of Pharmacy Services Warren General Hospital 8147233300-1822	4/3/2020 12:43 PM
Details	Last Recertification Date	Update	Recertification		8/21/2019 9:04:18 PM	8/21/2019 9:04 PM
Details	Entity Subname	Update	Recertification	WMG Youngsville Walk-In Care - Youngsville Walk-In Care	WMG Youngsville Walk-In Care	8/21/2019 9:04 PM
Details	State	Update		Approved	Active	1/1/2019 12:05 AM
Contacts	Signed By	Insert	New Registration		Longo, Louis Chief Financial Officer Warren General Hospital 8145732211-2308	10/23/2018 8:27 AM
Details	340B ID	Update	New Registration		DSH390146D	10/23/2018 8:27 AM
Details	Entity Subname	Update	New Registration	WMG Youngsville Walk-In Care	WMG Youngsville Walk-In Care - Youngsville Walk-In Care	10/23/2018 8:27 AM
Dates	Participating Approval Date	Update	New Registration		10/23/2018 8:27:51 AM	10/23/2018 8:27 AM
Details	State	Update	New Registration	Pending	Approved	10/23/2018 8:27 AM
Dates	Signed By Date	Update	New Registration		10/12/2018 1:24:20 PM	10/23/2018 8:27 AM
Dates	Start Date	Update	New Registration		1/1/2019 12:00:00 AM	10/23/2018 8:27 AM
Addresses	Main Address	Insert	New Registration		400 E. MAIN STREET YOUNGSVILLE, PA 16371	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007234970038	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007284970027	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007284970021	10/5/2018 2:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	10/5/2018 2:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1659360220	10/5/2018 2:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1508803701	10/5/2018 2:36 PM
Contacts	Primary Contact	Insert	New Registration		Wise, Damion Director of Pharmacy Services Warren General Hospital 8147233300-1822	10/5/2018 2:36 PM
Contacts	Authorizing Official	Insert	New Registration		Longo, Louis Chief Financial Officer Warren General Hospital 8145732211-2308	10/5/2018 2:36 PM
Details	Last Recertification Date	Insert	New Registration			10/5/2018 2:36 PM
Details	Grant Number	Insert	New Registration			10/5/2018 2:36 PM
Details	340B ID	Insert	New Registration			10/5/2018 2:36 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/5/2018 2:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/5/2018 2:36 PM
Details	Medicare Provider Number	Insert	New Registration		390146	10/5/2018 2:36 PM
Details	Entity Name	Insert	New Registration		WARREN GENERAL HOSPITAL	10/5/2018 2:36 PM
Details	Program Code	Insert	New Registration		DSH	10/5/2018 2:36 PM
Details	Entity Subname	Insert	New Registration		WMG Youngsville Walk-In Care	10/5/2018 2:36 PM
Dates	Participating Approval Date	Insert	New Registration			10/5/2018 2:36 PM
Details	State	Insert	New Registration		Pending	10/5/2018 2:36 PM
Dates	Registration Date	Insert	New Registration		10/5/2018 2:36:00 PM	10/5/2018 2:36 PM
Dates	Signed By Date	Insert	New Registration			10/5/2018 2:36 PM
Dates	Start Date	Insert	New Registration			10/5/2018 2:36 PM
Terminations	Termination Comments	Insert	New Registration			10/5/2018 2:36 PM
Terminations	Termination Date	Insert	New Registration			10/5/2018 2:36 PM
Terminations	Termination Effective Date	Insert	New Registration			10/5/2018 2:36 PM
Terminations	Termination Reason	Insert	New Registration			10/5/2018 2:36 PM