Covered Entity Details

CAH391316-06 WELLSBORO (Active) - information as of 6/19/2025 11:49:01 PM

Main Details

Name

WELLSBORO

Subdivision Name

SUSSH-UROLOGY - (85400)

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH391316-06

Medicare Provider Number

391316

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/7/2021

Participating Start Date

10/1/2021

Participating Approval Date

7/12/2021

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

UPMC Susquehanna
Roger C Yost, CFO, North-Central PA Region
(570) 321-3175

Primary Contact

UPMC
Anna V. Michalak, 340B Manager
(704) 438-7126

Addresses

Street Address

103 West Ave
Suite 201
Wellsboro, PA 16901

Billing Address

UPMC Presbyterian Shadyside DBA UPMC Pharmacy Supply Chain
PO Box 2058
Portland, OR 97208

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	1000037670010,1000037670013,1000037670008,1000037670017,1000037670012,1000037670005,1000037670009,1000037670014,1000037670019,1000037670018	1427501766,1457623316,1235294422,1275090433

Shipping Addresses

Shipping Address 1

UPMC Presbyterian Shadyside DBA UPMC Pharmacy Supply Chain
3175 E Carson St
Pittsburgh, PA 15203

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
CAH391316-01	Child	CAH	WELLSBORO	OFFICE OF FOOT AND ANKLE SERVICES - FOOT AND ANKLE	103 WEST AVE	WELLSBORO	PA	Active
CAH391316-02	Child	CAH	WELLSBORO	OFFICE OF INTERAL MEDICINE A DEPT - INTERNAL MEDICINE	103 WEST AVE	WELLSBORO	PA	Active
CAH391316-03	Child	CAH	WELLSBORO	SUSSH-OBGYN - (85394)	15 Meade St	Wellsboro	PA	Active
CAH391316-04	Child	CAH	WELLSBORO	SUSSH-GEN SURGERY - (85396)	1 Main St	Wellsboro	PA	Active
CAH391316-05	Child	CAH	WELLSBORO	SUSSH-ORTHOPEDICS - (85398)	9 Water St	Wellsboro	PA	Active
CAH391316-06	Child	CAH	WELLSBORO	SUSSH-UROLOGY - (85400)	103 West Ave	Wellsboro	PA	Active
CAH391316-07	Child	CAH	WELLSBORO	SUSSH-MEDICAL ONCOLOGY - - (33309)	15 Meade St	Wellsboro	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Insert	Group Change Request		UPMC Presbyterian Shadyside DBA UPMC Pharmacy Supply Chain PO Box 2058 Portland, OR 97208	5/15/2025 1:54 PM
Addresses	Shipping Address	Insert	Group Change Request		UPMC Presbyterian Shadyside DBA UPMC Pharmacy Supply Chain 3175 E Carson St Pittsburgh, PA 15203	5/15/2025 1:54 PM
Details	Last Recertification Date	Update	Recertification	8/24/2023 11:10:07 AM	9/4/2024 11:30:57 AM	9/4/2024 11:30 AM
Contacts	Primary Contact	Update	Group Change Request	Barner, Julie A. Director of Pharmacy UPMC Susquehanna 5703213295	Michalak, Anna V. 340B Manager UPMC 7044387126	1/29/2024 1:14 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 10:46:07 AM	8/24/2023 11:10:07 AM	8/24/2023 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670010	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670013	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670008	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670017	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670012	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670005	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670009	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670014	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670019	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000037670018	8/29/2022 10:46 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1427501766	8/29/2022 10:46 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1457623316	8/29/2022 10:46 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1235294422	8/29/2022 10:46 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1275090433	8/29/2022 10:46 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/29/2022 10:46 AM
Details	Last Recertification Date	Update	Recertification		8/29/2022 10:46:07 AM	8/29/2022 10:46 AM
Details	Entity Name	Update	Recertification	SOLDIERS AND SAILORS MEMORIAL HOSPITAL	WELLSBORO	8/29/2022 10:39 AM
Contacts	Authorizing Official	Update	Change Request	Stockhausen, Christopher CFO UPMC 4126642528	Yost, Roger C CFO, North-Central PA Region UPMC Susquehanna 5703213175	8/23/2022 5:05 PM
Details	State	Update		Approved	Active	10/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Stockhausen, Christopher CFO UPMC 4126642528	7/12/2021 11:04 AM
Details	340B ID	Update	New Registration		CAH391316-06	7/12/2021 11:04 AM
Details	Entity Name	Update	New Registration	SOLDIERS & SAILORS MEMORIAL HOSPT.	SOLDIERS AND SAILORS MEMORIAL HOSPITAL	7/12/2021 11:04 AM
Details	Entity Subname	Update	New Registration	SUSSH-UROLOGY	SUSSH-UROLOGY - (85400)	7/12/2021 11:04 AM
Dates	Participating Approval Date	Update	New Registration		7/12/2021 11:04:42 AM	7/12/2021 11:04 AM
Details	State	Update	New Registration	Pending	Approved	7/12/2021 11:04 AM
Dates	Signed By Date	Update	New Registration		7/7/2021 11:44:59 AM	7/12/2021 11:04 AM
Dates	Start Date	Update	New Registration		10/1/2021 12:00:00 AM	7/12/2021 11:04 AM
Addresses	Main Address	Insert	New Registration		103 West Ave Suite 201 Wellsboro, PA 16901	7/7/2021 11:44 AM
Contacts	Authorizing Official	Insert	New Registration		Stockhausen, Christopher CFO UPMC 4126642528	7/7/2021 11:44 AM
Contacts	Primary Contact	Insert	New Registration		Barner, Julie A. Director of Pharmacy UPMC Susquehanna 5703213295	7/7/2021 11:44 AM
Details	Assistance Received From Date	Insert	New Registration			7/7/2021 11:44 AM
Details	Assistance Received To Date	Insert	New Registration			7/7/2021 11:44 AM
Details	Last Recertification Date	Insert	New Registration			7/7/2021 11:44 AM
Details	Grant Number	Insert	New Registration			7/7/2021 11:44 AM
Details	340B ID	Insert	New Registration			7/7/2021 11:44 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/7/2021 11:44 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/7/2021 11:44 AM
Details	Medicare Provider Number	Insert	New Registration		391316	7/7/2021 11:44 AM
Details	Entity Name	Insert	New Registration		SOLDIERS & SAILORS MEMORIAL HOSPT.	7/7/2021 11:44 AM
Details	NOFO Number	Insert	New Registration			7/7/2021 11:44 AM
Details	Program Code	Insert	New Registration		CAH	7/7/2021 11:44 AM
Details	Entity Subname	Insert	New Registration		SUSSH-UROLOGY	7/7/2021 11:44 AM
Dates	Participating Approval Date	Insert	New Registration			7/7/2021 11:44 AM
Details	State	Insert	New Registration		Pending	7/7/2021 11:44 AM
Dates	Registration Date	Insert	New Registration		7/7/2021 11:44:55 AM	7/7/2021 11:44 AM
Dates	Signed By Date	Insert	New Registration			7/7/2021 11:44 AM
Dates	Start Date	Insert	New Registration			7/7/2021 11:44 AM
Terminations	Termination Comments	Insert	New Registration			7/7/2021 11:44 AM
Terminations	Termination Date	Insert	New Registration			7/7/2021 11:44 AM
Terminations	Termination Effective Date	Insert	New Registration			7/7/2021 11:44 AM
Terminations	Termination Reason	Insert	New Registration			7/7/2021 11:44 AM