Covered Entity Details

CAH331302-08 ELIZABETHTOWN COMMUNITY HOSPITAL (Active) - information as of 6/7/2025 4:45:07 AM

Main Details

Name

ELIZABETHTOWN COMMUNITY HOSPITAL

Subdivision Name

ELIZABETHTOWN COMMUNITY HOSPITAL - Emergency Department

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH331302-08

Medicare Provider Number

331302

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/10/2019

Participating Start Date

10/1/2019

Participating Approval Date

7/18/2019

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Porter Medical Center/Elizabethtown Community Hospital
Scott Alan Comeau, Vice President/Chief Financial Officer
(802) 388-4752

Primary Contact

Porter Medical Center / Elizabethtown Community Hospital
Renee Mosier, Pharmacy Director
(802) 388-4701 Ext: 5624

Addresses

Street Address

101 Adirondack Drive, Suite 1
Ticonderoga, NY 12883-1039

Billing Address

Elizabethtown Community Hospital
75 Park Street, PO Box 277
Elizabethtown, NY 12932

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?
No

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
CAH331302-01	Child	CAH	ELIZABETHTOWN COMMUNITY HOSPITAL	ELIZABETHTOWN COMMUNITY HEALTH CENTER	66 PARK STREET	ELIZABETHTOWN	NY	Active
CAH331302-02	Child	CAH	ELIZABETHTOWN COMMUNITY HOSPITAL	WESTPORT HEALTH CENTER	6097 NY-9N/Route 22	WESTPORT	NY	Active
CAH331302-03	Child	CAH	ELIZABETHTOWN COMMUNITY HOSPITAL	HIGH PEAKS HEALTH CENTER	18 Community Circle	WILMINGTON	NY	Active
CAH331302-04	Child	CAH	ELIZABETHTOWN COMMUNITY HOSPITAL	Smith House Health Center	39 Farrell Road	Willsboro	NY	Active
CAH331302-05	Child	CAH	ELIZABETHTOWN COMMUNITY HOSPITAL	AU SABLE FORKS HEALTH CENTER	15 Pleasant Street	AU SABLE FORKS	NY	Active
CAH331302-06	Child	CAH	ELIZABETHTOWN COMMUNITY HOSPITAL	CROWN POINT HEALTH CENTER	2679 Main Street	CROWN POINT	NY	Active
CAH331302-07	Child	CAH	ELIZABETHTOWN COMMUNITY HOSPITAL	ELIZABETHTOWN COMMUNITY HOSPITAL - Clinic	101 Adirondack Drive, Suite 1	TICONDEROGA	NY	Active
CAH331302-08	Child	CAH	ELIZABETHTOWN COMMUNITY HOSPITAL	ELIZABETHTOWN COMMUNITY HOSPITAL - Emergency Department	101 Adirondack Drive, Suite 1	Ticonderoga	NY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Comeau, Scott Alan CFO Elizabethtown Community Hospital 8023884752	Comeau, Scott Alan Vice President/Chief Financial Officer Porter Medical Center/Elizabethtown Community Hospital 8023884752	5/28/2025 7:49 AM
Contacts	Primary Contact	Update	Profile Change Request	Mosier, Renee Pharmacy Director Porter Medical Center 8023884701-5624	Mosier, Renee Pharmacy Director Porter Medical Center / Elizabethtown Community Hospital 8023884701-5624	5/15/2025 12:14 PM
Contacts	Primary Contact	Update	Change Request	Wright, Barbara 340B Program Analyst, Grants Manager Elizabethtown Community Hospital 5185853716	Mosier, Renee Pharmacy Director Porter Medical Center 8023884701-5624	12/4/2024 12:36 PM
Details	Last Recertification Date	Update	Recertification	9/5/2023 4:29:52 PM	8/21/2024 8:57:39 AM	8/21/2024 8:57 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 12:19:42 PM	9/5/2023 4:29:52 PM	9/5/2023 4:29 PM
Addresses	Billing Address	Insert	Change Request		Elizabethtown Community Hospital 75 Park Street, PO Box 277 Elizabethtown, NY 12932	2/6/2023 9:48 AM
Contacts	Primary Contact	Update	Profile Change Request	Wright, Barbara 340B Program Coordinator Elizabethtown Community Hospital 5185853716	Wright, Barbara 340B Program Analyst, Grants Manager Elizabethtown Community Hospital 5185853716	1/27/2023 12:25 PM
Contacts	Authorizing Official	Update	AO Change Request	Chardavoyne, Alan CFO Elizabethtown Community Hospital 5188733136	Comeau, Scott Alan CFO Elizabethtown Community Hospital 8023884752	9/13/2022 2:49 PM
Details	Last Recertification Date	Update	Recertification	8/18/2021 3:34:35 PM	8/31/2022 12:19:42 PM	8/31/2022 12:19 PM
Details	Last Recertification Date	Update	Recertification	8/28/2020 7:26:47 AM	8/18/2021 3:34:35 PM	8/18/2021 3:34 PM
Addresses	Main Address	Update	Recertification	1019 WICKER ST TICONDEROGA, NY 12883-1039	101 Adirondack Drive, Suite 1 TICONDEROGA, NY 12883-1039	8/28/2020 7:26 AM
Details	Last Recertification Date	Update	Recertification		8/28/2020 7:26:47 AM	8/28/2020 7:26 AM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		Chardavoyne, Alan CFO Elizabethtown Community Hospital 5188733136	7/18/2019 12:45 PM
Details	340B ID	Update	New Registration		CAH331302-08	7/18/2019 12:45 PM
Details	Entity Subname	Update	New Registration	ELIZABETHTOWN COMMUNITY HOSPITAL	ELIZABETHTOWN COMMUNITY HOSPITAL - Emergency Department	7/18/2019 12:45 PM
Dates	Participating Approval Date	Update	New Registration		7/18/2019 12:45:51 PM	7/18/2019 12:45 PM
Details	State	Update	New Registration	Pending	Approved	7/18/2019 12:45 PM
Dates	Signed By Date	Update	New Registration		7/10/2019 3:55:00 PM	7/18/2019 12:45 PM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	7/18/2019 12:45 PM
Addresses	Main Address	Insert	New Registration		1019 WICKER ST TICONDEROGA, NY 12883-1039	7/10/2019 3:54 PM
Contacts	Authorizing Official	Insert	New Registration		Chardavoyne, Alan CFO Elizabethtown Community Hospital 5188733136	7/10/2019 3:54 PM
Contacts	Primary Contact	Insert	New Registration		Wright, Barbara 340B Program Coordinator Elizabethtown Community Hospital 5185853716	7/10/2019 3:54 PM
Details	Last Recertification Date	Insert	New Registration			7/10/2019 3:54 PM
Details	Grant Number	Insert	New Registration			7/10/2019 3:54 PM
Details	340B ID	Insert	New Registration			7/10/2019 3:54 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/10/2019 3:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/10/2019 3:54 PM
Details	Medicare Provider Number	Insert	New Registration		331302	7/10/2019 3:54 PM
Details	Entity Name	Insert	New Registration		ELIZABETHTOWN COMMUNITY HOSPITAL	7/10/2019 3:54 PM
Details	Program Code	Insert	New Registration		CAH	7/10/2019 3:54 PM
Details	Entity Subname	Insert	New Registration		ELIZABETHTOWN COMMUNITY HOSPITAL	7/10/2019 3:54 PM
Dates	Participating Approval Date	Insert	New Registration			7/10/2019 3:54 PM
Details	State	Insert	New Registration		Pending	7/10/2019 3:54 PM
Dates	Registration Date	Insert	New Registration		7/10/2019 3:54:56 PM	7/10/2019 3:54 PM
Dates	Signed By Date	Insert	New Registration			7/10/2019 3:54 PM
Dates	Start Date	Insert	New Registration			7/10/2019 3:54 PM
Terminations	Termination Comments	Insert	New Registration			7/10/2019 3:54 PM
Terminations	Termination Date	Insert	New Registration			7/10/2019 3:54 PM
Terminations	Termination Effective Date	Insert	New Registration			7/10/2019 3:54 PM
Terminations	Termination Reason	Insert	New Registration			7/10/2019 3:54 PM