Covered Entity Details

RRC490059-01 ST. MARYS HOSPITAL (Terminated) - information as of 6/12/2025 5:57:30 AM

Main Details

Name

ST. MARYS HOSPITAL

Subdivision Name

WEST END INTERNAL MEDICINE - Internal Medicine

Type

Rural Referral Center

Rural

340B ID

RRC490059-01

Medicare Provider Number

490059

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/7/2021

Participating Start Date

10/1/2021

Participating Approval Date

8/20/2021

Last Recertification Date

8/22/2023

Termination Date
Termination Reason

10/1/2024
Change of covered entity type

Contacts

Authorizing Official

Bon Secours Mercy Health
Gregory S Simmons, Site CFO
(804) 248-8731

Primary Contact

Bon Secours - St. Mary's Hospital
Caroline Briggs, Director of Pharmacy
(804) 287-7807

Addresses

Street Address

7001 FOREST AVE
STE 2500
RICHMOND, VA 23230-1726

Billing Address

St. Mary's Hospital
5801 Bremo Road
Richmond, VA 23226

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
VA	4900596	1962464016

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
RRC490059-01	Child	RRC	ST. MARYS HOSPITAL	WEST END INTERNAL MEDICINE - Internal Medicine	7001 FOREST AVE	RICHMOND	VA	Terminated
RRC490059-02	Child	RRC	ST. MARYS HOSPITAL	BON SECOURS MONUMENT INTERNAL MEDIC - Internal Medicine	5855 BREMO RD	RICHMOND	VA	Terminated
RRC490059-03	Child	RRC	ST. MARYS HOSPITAL	COMMONWEALTH INTERNAL MEDICINE ASSO - Internal Medicine	9220 FOREST HILL AVE	RICHMOND	VA	Terminated
RRC490059-04	Child	RRC	ST. MARYS HOSPITAL	BON SECOURS SHORT PUMP EMERGENCY CE - EMERGENCY	12320 W BROAD ST STE 100	HENRICO	VA	Terminated
RRC490059-05	Child	RRC	ST. MARYS HOSPITAL	PATTERSON AVENUE FAMILY PRACTICE - Family Practice	9600 PATTERSON AVE	RICHMOND	VA	Terminated
RRC490059-06	Child	RRC	ST. MARYS HOSPITAL	CARDIOVASCULAR ASSOCIATES OF VIRGIN - Cardiovascular	7001 FOREST AVE	RICHMOND	VA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Briggs, Caroline Director of Pharmacy St. Mary's Hospital 8042877807	Briggs, Caroline Director of Pharmacy Bon Secours - St. Mary's Hospital 8042877807	2/7/2025 7:40 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		10/1/2024 12:00:00 AM	7/12/2024 8:37 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	7/12/2024 8:37 AM
Terminations	Termination Date	Update	Hospital Type Change Request		10/1/2024 12:00:00 AM	7/12/2024 8:37 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		10/1/2024 12:00:00 AM	7/12/2024 8:37 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	7/12/2024 8:37 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 12:12:06 PM	8/22/2023 11:20:26 AM	8/22/2023 11:20 AM
Contacts	Authorizing Official	Update	AO Change Request	Kusnierz, William Joseph CFO - Richmond Market Bon Secours Mercy Health 5132628762	Simmons, Gregory S Site CFO Bon Secours Mercy Health 8042488731	7/21/2023 8:25 AM
Contacts	Authorizing Official	Update	Profile Change Request	Kusnierz, William Joseph Market CFO Community Mercy Health Partners 9375235512	Kusnierz, William Joseph CFO - Richmond Market Bon Secours Mercy Health 5132628762	6/13/2023 2:01 PM
Contacts	Authorizing Official	Update	AO Change Request	Giorgiani, Ryan CFO Bon Secours Mercy Health 8044538864	Kusnierz, William Joseph Market CFO Community Mercy Health Partners 9375235512	4/26/2023 9:58 AM
Details	Last Recertification Date	Update	Recertification		8/31/2022 12:12:06 PM	8/31/2022 12:12 PM
Contacts	Signed By	Update	Profile Change Request	Haynes, Jonathan Lee Site CFO III Bon Secours Mercy Health 8042818548	Haynes, Jonathan Lee Hampton Roads Market CFO Bon Secours Mercy Health 5402702809	7/28/2022 4:22 PM
Contacts	Primary Contact	Update	Group Change Request	Fairfield, Autumn 340B Manager Bon Secours Mercy Health 2702174090	Briggs, Caroline Director of Pharmacy St. Mary's Hospital 8042877807	2/22/2022 7:19 AM
Contacts	Authorizing Official	Update	AO Change Request	Haynes, Jonathan Lee Site CFO III Bon Secours Mercy Health 8042818548	Giorgiani, Ryan CFO Bon Secours Mercy Health 8044538864	1/24/2022 7:40 AM
Details	State	Update		Approved	Active	10/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Haynes, Jonathan Lee Site CFO III Bon Secours Mercy Health 8042818548	8/20/2021 9:39 AM
Details	340B ID	Update	New Registration		RRC490059-01	8/20/2021 9:39 AM
Details	Entity Subname	Update	New Registration	WEST END INTERNAL MEDICINE	WEST END INTERNAL MEDICINE - Internal Medicine	8/20/2021 9:39 AM
Dates	Participating Approval Date	Update	New Registration		8/20/2021 9:39:23 AM	8/20/2021 9:39 AM
Details	State	Update	New Registration	Pending	Approved	8/20/2021 9:39 AM
Dates	Signed By Date	Update	New Registration		8/9/2021 4:05:09 PM	8/20/2021 9:39 AM
Dates	Start Date	Update	New Registration		10/1/2021 12:00:00 AM	8/20/2021 9:39 AM
Contacts	Authorizing Official	Update	Profile Change Request	Haynes, Jonathan Lee Site CFO III Bon Secours Mercy Health 8045947408	Haynes, Jonathan Lee Site CFO III Bon Secours Mercy Health 8042818548	7/7/2021 2:08 PM
Addresses	Main Address	Insert	New Registration		7001 FOREST AVE STE 2500 RICHMOND, VA 23230-1726	7/7/2021 1:02 PM
Addresses	Billing Address	Insert	New Registration		St. Mary's Hospital 5801 Bremo Road Richmond, VA 23226	7/7/2021 1:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/7/2021 1:02 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4900596	7/7/2021 1:02 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	7/7/2021 1:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1962464016	7/7/2021 1:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		VA	7/7/2021 1:02 PM
Contacts	Authorizing Official	Insert	New Registration		Haynes, Jonathan Lee Site CFO III Bon Secours Mercy Health 8045947408	7/7/2021 1:02 PM
Contacts	Primary Contact	Insert	New Registration		Fairfield, Autumn 340B Manager Bon Secours Mercy Health 2702174090	7/7/2021 1:02 PM
Details	Assistance Received From Date	Insert	New Registration			7/7/2021 1:02 PM
Details	Assistance Received To Date	Insert	New Registration			7/7/2021 1:02 PM
Details	Last Recertification Date	Insert	New Registration			7/7/2021 1:02 PM
Details	Grant Number	Insert	New Registration			7/7/2021 1:02 PM
Details	340B ID	Insert	New Registration			7/7/2021 1:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/7/2021 1:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/7/2021 1:02 PM
Details	Medicare Provider Number	Insert	New Registration		490059	7/7/2021 1:02 PM
Details	Entity Name	Insert	New Registration		ST. MARYS HOSPITAL	7/7/2021 1:02 PM
Details	NOFO Number	Insert	New Registration			7/7/2021 1:02 PM
Details	Program Code	Insert	New Registration		RRC	7/7/2021 1:02 PM
Details	Entity Subname	Insert	New Registration		WEST END INTERNAL MEDICINE	7/7/2021 1:02 PM
Dates	Participating Approval Date	Insert	New Registration			7/7/2021 1:02 PM
Details	State	Insert	New Registration		Pending	7/7/2021 1:02 PM
Dates	Registration Date	Insert	New Registration		7/7/2021 1:02:50 PM	7/7/2021 1:02 PM
Dates	Signed By Date	Insert	New Registration			7/7/2021 1:02 PM
Dates	Start Date	Insert	New Registration			7/7/2021 1:02 PM
Terminations	Termination Comments	Insert	New Registration			7/7/2021 1:02 PM
Terminations	Termination Date	Insert	New Registration			7/7/2021 1:02 PM
Terminations	Termination Effective Date	Insert	New Registration			7/7/2021 1:02 PM
Terminations	Termination Reason	Insert	New Registration			7/7/2021 1:02 PM