Covered Entity Details

DSH330180BB SAMARITAN HOSPITAL (Terminated) - information as of 4/25/2025 6:33:37 PM

Main Details

Name

SAMARITAN HOSPITAL

Subdivision Name

CAPITAL DISTRICT INTERNAL MEDICINE - Internal Medicine

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH330180BB

Medicare Provider Number

330180

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/13/2020

Participating Start Date

1/1/2021

Participating Approval Date

11/4/2020

Last Recertification Date

8/27/2022

Termination Date
Termination Reason

10/1/2023
Site closure

Contacts

Authorizing Official

Samaritan Hospital of Troy NY
Lori Santos, CFO
(518) 525-5537

Primary Contact

Samaritan Hospital
Dario Pantano, Pharmacy Manager
(518) 271-3454

Addresses

Street Address

1440 WESTERN AVENUE
ALBANY, NY 12203-3421

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?
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
DSH330180A	Child	DSH	SAMARITAN HOSPITAL	ST PETERS URGENT CARE - Urgent Care	79 VANDENBURGH AVE	TROY	NY	Terminated
DSH330180AA	Child	DSH	SAMARITAN HOSPITAL	St. Peter's Urgent Care - Troy - Urgent Care	1300 Massachusettes Ave	Troy	NY	Terminated
DSH330180AB	Child	DSH	SAMARITAN HOSPITAL	Hildegard Medicus Cancer Center - Radiation Oncology	1300 Massachusettes Ave	Troy	NY	Terminated
DSH330180AC	Child	DSH	SAMARITAN HOSPITAL	St. Mary's Endoscopy Center - Endoscopy	1300 Massachusettes Ave	Troy	NY	Terminated
DSH330180AD	Child	DSH	SAMARITAN HOSPITAL	Hildegard Medicus Cancer Center - Medical Oncology	1300 Massachusettes Ave	Troy	NY	Active
DSH330180AE	Child	DSH	SAMARITAN HOSPITAL	Troy Internal Medicine - Primary Care	1401 Massachusettes Ave	Troy	NY	Active
DSH330180AF	Child	DSH	SAMARITAN HOSPITAL	Wound Care and Hyperbaric Program - Wound Care	147 Hoosick St	Troy	NY	Terminated
DSH330180AG	Child	DSH	SAMARITAN HOSPITAL	Incontinence Treatment Center - Incontinence Treatment	147 Hoosick St	Troy	NY	Terminated
DSH330180AH	Child	DSH	SAMARITAN HOSPITAL	Anticoagulation Clinic - Troy - Anticoagulation Clinic	147 Hoosick St	Troy	NY	Active
DSH330180AJ	Child	DSH	SAMARITAN HOSPITAL	Capital Region Family Health Center - Primary Care	2 Empire Dr	Rensselaer	NY	Active
DSH330180AK	Child	DSH	SAMARITAN HOSPITAL	St. Peter's Urgent Care - East Greenbush - Urgent Care	2 Empire Dr	Rensselaer	NY	Terminated
DSH330180AL	Child	DSH	SAMARITAN HOSPITAL	Samaritan OBGYN - East Greenbush - OB/GYN	2 Empire Drive	Rensselaer	NY	Active
DSH330180AM	Child	DSH	SAMARITAN HOSPITAL	Samaritan OB/GYN - Troy - OB/GYN	2231 Burdett Ave	Troy	NY	Active
DSH330180AN	Child	DSH	SAMARITAN HOSPITAL	Troy Pediatric Health Center - Pediatrics	1300 Massachusetts Ave	Troy	NY	Active
DSH330180AP	Child	DSH	SAMARITAN HOSPITAL	Samaritan OBGYN - Cohoes - OB/GYN	55 Mohawk St	Cohoes	NY	Terminated
DSH330180AQ	Child	DSH	SAMARITAN HOSPITAL	Samaritan OBGYN - Latham - OB/GYN	713 Troy-Schenectady Road	Latham	NY	Active
DSH330180AR	Child	DSH	SAMARITAN HOSPITAL	Samaritan OBGYN - Clifton Park - OB/GYN	855 Rt 146	Clifton Park	NY	Active
DSH330180AS	Child	DSH	SAMARITAN HOSPITAL	St. Peter's Internal Medicine - Primary Care	147 Hoosick St	Troy	NY	Active
DSH330180AT	Child	DSH	SAMARITAN HOSPITAL	Clifton Park Family Practice - family practice	1 Tallow Wood Drive	Clifton Park	NY	Active
DSH330180AU	Child	DSH	SAMARITAN HOSPITAL	Stillwater Family Health Center - Primary Care	1111 Hudson Ave	Stillwater	NY	Active
DSH330180AV	Child	DSH	SAMARITAN HOSPITAL	ST. PETER'S PELVIC HEALTH CENTER - Pelvic Health	600 NORTHERN BLVD 3RD FLOOR	ALBANY	NY	Active
DSH330180AW	Child	DSH	SAMARITAN HOSPITAL	St. Peter's Health Partners Infusion Center - AMH Campus - Infusion Services	600 Northern Blvd 4th floor	Albany	NY	Active
DSH330180AX	Child	DSH	SAMARITAN HOSPITAL	Anticoagulation Clinic - AMH Campus - Anticoagulation Clinic	600 Northern Blvd 1st Floor	Albany	NY	Active
DSH330180AY	Child	DSH	SAMARITAN HOSPITAL	INTERNAL MEDICINE ASSOCIATES - Internal Medicine	63 SHAKER ROAD SUITE G02	ALBANY	NY	Active
DSH330180AZ	Child	DSH	SAMARITAN HOSPITAL	St. Peter's Health Partners Outpatient Wound Care - Wound Care	600 Northern Blvd 6th Floor	Albany	NY	Active
DSH330180B	Child	DSH	SAMARITAN HOSPITAL	MENTAL HEALTH PROS CLINIC - Behavioral Health	1801 6th Ave	Troy	NY	Active
DSH330180BA	Child	DSH	SAMARITAN HOSPITAL	Troy Surgery Associates - Surgery Services	1 Tallow Wood Dr.	Clifton Park	NY	Terminated
DSH330180BB	Child	DSH	SAMARITAN HOSPITAL	CAPITAL DISTRICT INTERNAL MEDICINE - Internal Medicine	1440 WESTERN AVENUE	ALBANY	NY	Terminated
DSH330180BC	Child	DSH	SAMARITAN HOSPITAL	Emergency Department - AMH Campus - Emergency Department	600 Northern Blvd 1st Floor	Albany	NY	Active
DSH330180C	Child	DSH	SAMARITAN HOSPITAL	ST PETER'S DIABETES & ENDOCRINE CARE - Endocrinology	279 Troy Rd	Rensselaer	NY	Terminated
DSH330180D	Child	DSH	SAMARITAN HOSPITAL	COHOES FAMILY CARE - Family Medicine	55 MOHAWK ST	COHOES	NY	Active
DSH330180E	Child	DSH	SAMARITAN HOSPITAL	TROY INFECTIOUS DISEASE - Infectious Disease	Samaritan Medical Arts Building	Troy	NY	Terminated
DSH330180F	Child	DSH	SAMARITAN HOSPITAL	SPECIALTY SURGEONS - Thoracic and Esophageal	Samaritan Medical Arts Building	Troy	NY	Terminated
DSH330180G	Child	DSH	SAMARITAN HOSPITAL	ST PETER'S DIABETES & ENDOCRINE CARE - Endocrinology	55 Mohawk St	Cohoes	NY	Terminated
DSH330180H	Child	DSH	SAMARITAN HOSPITAL	TROY SURGICAL ASSOCIATES - Surgery	Samaritan Medical Arts Building	Troy	NY	Active
DSH330180J	Child	DSH	SAMARITAN HOSPITAL	RVERSIDE ORTHOPEDICS - Orthopedic Surgery	35 Lower Hudson Ave	Green Island	NY	Terminated
DSH330180K	Child	DSH	SAMARITAN HOSPITAL	ST PETER'S DIABETES & ENDOCRINE CARE - Endocrinology	158 Saratoga Ave	Waterford	NY	Terminated
DSH330180L	Child	DSH	SAMARITAN HOSPITAL	RIVERSIDE ORTHOPEDICS - Orthopedic Surgery	279 Troy Rd	Rensselaer	NY	Terminated
DSH330180M	Child	DSH	SAMARITAN HOSPITAL	TROY FAMILY HEALTH CENTER - Family Medicine	79 VANDENBURGH AVE	TROY	NY	Active
DSH330180N	Child	DSH	SAMARITAN HOSPITAL	FAMILY MEDICAL GROUP - Family Medicine	279 Troy Rd	Rensselaer	NY	Active
DSH330180P	Child	DSH	SAMARITAN HOSPITAL	WATERFORD HEALTH CENTER - Internal Medicine	158 SARATOGA AVE	WATERFORD	NY	Active
DSH330180Q	Child	DSH	SAMARITAN HOSPITAL	RIVERSIDE MEDICAL CENTER - Family Medicine	35 LOWER HUDSON AVE	GREEN ISLAND	NY	Active
DSH330180R	Child	DSH	SAMARITAN HOSPITAL	TROY UROLOGICAL ASSOCIATES - Urology	Samaritan Medical Arts Building	Troy	NY	Terminated
DSH330180S	Child	DSH	SAMARITAN HOSPITAL	MENTAL HEALTH SATELITE CLINIC - Behavioral Health	1801 6th Ave	Troy	NY	Terminated
DSH330180T	Child	DSH	SAMARITAN HOSPITAL	Latham Primary Care Associates - Primary Care	1 Bell Tower Drive	Watervliet	NY	Active
DSH330180U	Child	DSH	SAMARITAN HOSPITAL	Clifton Park Urgent Care - Urgent Care	1 Tallow Wood Drive	Clifton Park	NY	Terminated
DSH330180V	Child	DSH	SAMARITAN HOSPITAL	Clifton Park Pediatrics - Pediatrics	1 Tallow Wood Drive	Clifton Park	NY	Active
DSH330180W	Child	DSH	SAMARITAN HOSPITAL	Anticoagulation Clinic - Clifton Park - Anticoagulation Clinic	1 Tallow Wood Drive	Clifton Park	NY	Active
DSH330180X	Child	DSH	SAMARITAN HOSPITAL	St. Mary's Outpatient Detoxification - Detoxification	1300 Massachusettes Ave	Troy	NY	Terminated
DSH330180Y	Child	DSH	SAMARITAN HOSPITAL	St. Mary's Sleep Center - Sleep Center	1300 Massachusettes Ave	Troy	NY	Active
DSH330180Z	Child	DSH	SAMARITAN HOSPITAL	Hildegard Medicus Cancer Center - Infusion Center	1300 Massachusettes Ave	Troy	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/7/2023 12:00:00 AM	7/18/2023 8:31 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/18/2023 8:31 AM
Terminations	Termination Date	Update	Termination Request		10/1/2023 12:00:00 AM	7/18/2023 8:31 AM
Terminations	Termination Effective Date	Update	Termination Request		7/7/2023 12:00:00 AM	7/18/2023 8:31 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	7/18/2023 8:31 AM
Details	Last Recertification Date	Update	Recertification	8/25/2021 3:52:14 PM	8/27/2022 1:23:30 PM	8/27/2022 1:23 PM
Details	Last Recertification Date	Update	Recertification		8/25/2021 3:52:14 PM	8/25/2021 3:52 PM
Contacts	Primary Contact	Update	Change Request	KENNICUTT, JEANNE MGR AMBULATORY CARE PHARMACY SERVICES Samaritan Hospital of Troy NY 5185256132	Pantano, Dario Pharmacy Manager Samaritan Hospital 5182713454	4/28/2021 9:03 PM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Santos, Lori CFO Samaritan Hospital of Troy NY 5185255537	11/4/2020 12:33 PM
Details	340B ID	Update	New Registration		DSH330180BB	11/4/2020 12:33 PM
Details	Entity Subname	Update	New Registration	CAPITAL DISTRICT INTERNAL MEDICINE	CAPITAL DISTRICT INTERNAL MEDICINE - Internal Medicine	11/4/2020 12:33 PM
Dates	Participating Approval Date	Update	New Registration		11/4/2020 12:33:48 PM	11/4/2020 12:33 PM
Details	State	Update	New Registration	Pending	Approved	11/4/2020 12:33 PM
Dates	Signed By Date	Update	New Registration		11/4/2020 9:54:32 AM	11/4/2020 12:33 PM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	11/4/2020 12:33 PM
Addresses	Main Address	Insert	New Registration		1440 WESTERN AVENUE ALBANY, NY 12203-3421	10/13/2020 1:24 PM
Contacts	Primary Contact	Insert	New Registration		KENNICUTT, JEANNE MGR AMBULATORY CARE PHARMACY SERVICES Samaritan Hospital of Troy NY 5185256132	10/13/2020 1:24 PM
Contacts	Authorizing Official	Insert	New Registration		Santos, Lori CFO Samaritan Hospital of Troy NY 5185255537	10/13/2020 1:24 PM
Details	Assistance Received From Date	Insert	New Registration			10/13/2020 1:24 PM
Details	Assistance Received To Date	Insert	New Registration			10/13/2020 1:24 PM
Details	Last Recertification Date	Insert	New Registration			10/13/2020 1:24 PM
Details	Grant Number	Insert	New Registration			10/13/2020 1:24 PM
Details	340B ID	Insert	New Registration			10/13/2020 1:24 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/13/2020 1:24 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/13/2020 1:24 PM
Details	Medicare Provider Number	Insert	New Registration		330180	10/13/2020 1:24 PM
Details	Entity Name	Insert	New Registration		SAMARITAN HOSPITAL	10/13/2020 1:24 PM
Details	NOFO Number	Insert	New Registration			10/13/2020 1:24 PM
Details	Program Code	Insert	New Registration		DSH	10/13/2020 1:24 PM
Details	Entity Subname	Insert	New Registration		CAPITAL DISTRICT INTERNAL MEDICINE	10/13/2020 1:24 PM
Dates	Participating Approval Date	Insert	New Registration			10/13/2020 1:24 PM
Details	State	Insert	New Registration		Pending	10/13/2020 1:24 PM
Dates	Registration Date	Insert	New Registration		10/13/2020 1:24:40 PM	10/13/2020 1:24 PM
Dates	Signed By Date	Insert	New Registration			10/13/2020 1:24 PM
Dates	Start Date	Insert	New Registration			10/13/2020 1:24 PM
Terminations	Termination Comments	Insert	New Registration			10/13/2020 1:24 PM
Terminations	Termination Date	Insert	New Registration			10/13/2020 1:24 PM
Terminations	Termination Effective Date	Insert	New Registration			10/13/2020 1:24 PM
Terminations	Termination Reason	Insert	New Registration			10/13/2020 1:24 PM