Covered Entity Details

DSH070029 BRISTOL HOSPITAL INC (Active) - information as of 5/13/2025 11:03:12 PM

Main Details

Name

BRISTOL HOSPITAL INC

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH070029

Medicare Provider Number

070029

Additional Details

Current Program Status

Active

Registration Date

7/1/2019

Participating Start Date

10/1/2019

Participating Approval Date

7/25/2019

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Bristol Hospital
Kurt Barwis, President
(860) 585-3222

Primary Contact

Bristol Hospital
Timothy Ajayi, CFO
(860) 585-3024

Addresses

Street Address

41 BREWSTER ROAD
BRISTOL, CT 06010

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	004025193	1619901642

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	07/14/2023	10/01/2023	10/01/2023
Contract Detail	BRISTOL HEALTH PHARMACY, LLC	BRISTOL HOSPITAL	41 BREWSTER RD	BRISTOL	CT	06010	04/13/2021	07/01/2021	07/01/2021
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	07/14/2023	10/01/2023	10/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH070029A	Child	DSH	BRISTOL HOSPITAL INC	BRISTOL HOSPITAL COUNSELING CENTER - Behavioral Health Services	420 N MAIN ST	BRISTOL	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/21/2023 2:19:03 PM	9/3/2024 2:02:50 PM	9/3/2024 2:02 PM
Details	Last Recertification Date	Update	Recertification	9/12/2022 11:07:14 AM	8/21/2023 2:19:03 PM	8/21/2023 2:19 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 10:35:36 AM	9/12/2022 11:07:14 AM	9/12/2022 11:07 AM
Contacts	Primary Contact	Update	PC Change Request	Bak, Veda Manager of Reimbursement Bristol Hospital 8605853814	Ajayi, Timothy CFO Bristol Hospital 8605853024	7/25/2022 6:39 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 2:37:55 PM	9/7/2021 10:35:36 AM	9/7/2021 10:35 AM
Medicaid Billing	NPI: State	Update	Recertification		CT	8/26/2020 2:37 PM
Details	Last Recertification Date	Update	Recertification		8/26/2020 2:37:55 PM	8/26/2020 2:37 PM
Contacts	Authorizing Official	Update	Change Request	Braam, Richard A CFO Bristol Hospital 8605853575	Barwis, Kurt President Bristol Hospital 8605853222	4/23/2020 1:12 PM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Addresses	Main Address	Update	Change Request	41 BREWSTER ROAD BRISTOL, CT 06011-0977	41 BREWSTER ROAD BRISTOL, CT 06010	8/29/2019 6:58 AM
Addresses	Main Address	Update	Change Request	BREWSTER ROAD BRISTOL, CT 06111-0977	41 BREWSTER ROAD BRISTOL, CT 06011-0977	8/27/2019 9:35 AM
Contacts	Signed By	Insert	New Registration		Braam, Richard A CFO Bristol Hospital 8605853575	7/25/2019 7:46 AM
Details	340B ID	Update	New Registration		DSH070029	7/25/2019 7:46 AM
Dates	Participating Approval Date	Update	New Registration		7/25/2019 7:46:22 AM	7/25/2019 7:46 AM
Details	State	Update	New Registration	Pending	Approved	7/25/2019 7:46 AM
Dates	Signed By Date	Update	New Registration		7/1/2019 4:57:41 PM	7/25/2019 7:46 AM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	7/25/2019 7:46 AM
Addresses	Main Address	Insert	New Registration		BREWSTER ROAD BRISTOL, CT 06111-0977	7/1/2019 11:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/1/2019 11:33 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004025193	7/1/2019 11:33 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	7/1/2019 11:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1619901642	7/1/2019 11:33 AM
Contacts	Primary Contact	Insert	New Registration		Bak, Veda Manager of Reimbursement Bristol Hospital 8605853814	7/1/2019 11:33 AM
Contacts	Authorizing Official	Insert	New Registration		Braam, Richard A CFO Bristol Hospital 8605853575	7/1/2019 11:33 AM
Details	Last Recertification Date	Insert	New Registration			7/1/2019 11:33 AM
Details	Grant Number	Insert	New Registration			7/1/2019 11:33 AM
Details	340B ID	Insert	New Registration			7/1/2019 11:33 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/1/2019 11:33 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/1/2019 11:33 AM
Details	Medicare Provider Number	Insert	New Registration		070029	7/1/2019 11:33 AM
Details	Entity Name	Insert	New Registration		BRISTOL HOSPITAL INC	7/1/2019 11:33 AM
Details	Program Code	Insert	New Registration		DSH	7/1/2019 11:33 AM
Details	Entity Subname	Insert	New Registration			7/1/2019 11:33 AM
Dates	Participating Approval Date	Insert	New Registration			7/1/2019 11:33 AM
Details	State	Insert	New Registration		Pending	7/1/2019 11:33 AM
Dates	Registration Date	Insert	New Registration		7/1/2019 11:33:32 AM	7/1/2019 11:33 AM
Dates	Signed By Date	Insert	New Registration			7/1/2019 11:33 AM
Dates	Start Date	Insert	New Registration			7/1/2019 11:33 AM
Terminations	Termination Comments	Insert	New Registration			7/1/2019 11:33 AM
Terminations	Termination Date	Insert	New Registration			7/1/2019 11:33 AM
Terminations	Termination Effective Date	Insert	New Registration			7/1/2019 11:33 AM
Terminations	Termination Reason	Insert	New Registration			7/1/2019 11:33 AM