Covered Entity Details

RRC390079-03 ROBERT PACKER HOSPITAL (Active) - information as of 5/19/2025 12:41:50 AM

Main Details

Name

ROBERT PACKER HOSPITAL

Subdivision Name

ROBERT PACKER HOSPITAL TOWANDA CAMP - Respiratory Therapy

Type

Rural Referral Center

Rural

Yes

340B ID

RRC390079-03

Medicare Provider Number

390079

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/8/2022

Participating Start Date

7/1/2022

Participating Approval Date

4/11/2022

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

The Guthrie Clinic
Matthew David Denniston, VP, Pharmacy Services
(570) 887-6626

Primary Contact

Robert Packer Hospital
Heather Lee Lodge, Pharmacy Services Financial Analyst
(570) 887-4375

Addresses

Street Address

91 HOSPITAL DR
TOWANDA, PA 18848-9702

Billing Address

The Guthrie Clinic
One Guthrie Square
Sayre, PA 18840

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
NY	3002462	1083614382
PA	100706140003	1083614382

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
RRC390079-01	Child	RRC	ROBERT PACKER HOSPITAL	ROBERT PACKER HOSPITAL TOWANDA CAMP - Emergency	91 HOSPITAL DR	TOWANDA	PA	Active
RRC390079-02	Child	RRC	ROBERT PACKER HOSPITAL	ROBERT PACKER HOSPITAL TOWANDA CAMP - Cardiovascular Diagnostic	91 HOSPITAL DR	TOWANDA	PA	Active
RRC390079-03	Child	RRC	ROBERT PACKER HOSPITAL	ROBERT PACKER HOSPITAL TOWANDA CAMP - Respiratory Therapy	91 HOSPITAL DR	TOWANDA	PA	Active
RRC390079-04	Child	RRC	ROBERT PACKER HOSPITAL	ROBERT PACKER HOSPITAL TOWANDA CAMP - Medical Oncology	91 HOSPITAL DR	TOWANDA	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Insert	Change Request		The Guthrie Clinic One Guthrie Square Sayre, PA 18840	4/22/2025 11:13 AM
Contacts	Authorizing Official	Update	Change Request	Macafee, Fran Chief Financial Officer Robert Packer Hospital 5708875985	Denniston, Matthew David VP, Pharmacy Services The Guthrie Clinic 5708876626	10/28/2024 1:48 PM
Contacts	Primary Contact	Update	Recertification	Denniston, Matthew David VP, Pharmacy Services The Guthrie Clinic 5708876626	Lodge, Heather Lee Pharmacy Services Financial Analyst Robert Packer Hospital 5708874375	9/6/2024 11:59 AM
Details	Last Recertification Date	Update	Recertification	9/11/2023 9:23:30 AM	9/6/2024 11:59:14 AM	9/6/2024 11:59 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 1:18:24 PM	9/11/2023 9:23:30 AM	9/11/2023 9:23 AM
Details	Last Recertification Date	Update	Recertification		8/30/2022 1:18:24 PM	8/30/2022 1:18 PM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Macafee, Fran Chief Financial Officer Robert Packer Hospital 5708875985	4/11/2022 12:33 PM
Details	340B ID	Update	New Registration		RRC390079-03	4/11/2022 12:33 PM
Details	Entity Subname	Update	New Registration	ROBERT PACKER HOSPITAL TOWANDA CAMP	ROBERT PACKER HOSPITAL TOWANDA CAMP - Respiratory Therapy	4/11/2022 12:33 PM
Dates	Participating Approval Date	Update	New Registration		4/11/2022 12:33:22 PM	4/11/2022 12:33 PM
Details	State	Update	New Registration	Pending	Approved	4/11/2022 12:33 PM
Dates	Signed By Date	Update	New Registration		4/8/2022 12:27:08 PM	4/11/2022 12:33 PM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	4/11/2022 12:33 PM
Addresses	Main Address	Insert	New Registration		91 HOSPITAL DR TOWANDA, PA 18848-9702	4/8/2022 12:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2022 12:07 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		3002462	4/8/2022 12:07 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	4/8/2022 12:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2022 12:07 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100706140003	4/8/2022 12:07 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/8/2022 12:07 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083614382	4/8/2022 12:07 PM
Medicaid Billing	NPI: State	Insert	New Registration		NY	4/8/2022 12:07 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1083614382	4/8/2022 12:07 PM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/8/2022 12:07 PM
Contacts	Authorizing Official	Insert	New Registration		Macafee, Fran Chief Financial Officer Robert Packer Hospital 5708875985	4/8/2022 12:07 PM
Contacts	Primary Contact	Insert	New Registration		Denniston, Matthew David VP, Pharmacy Services The Guthrie Clinic 5708876626	4/8/2022 12:07 PM
Details	Assistance Received From Date	Insert	New Registration			4/8/2022 12:07 PM
Details	Assistance Received To Date	Insert	New Registration			4/8/2022 12:07 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2022 12:07 PM
Details	Grant Number	Insert	New Registration			4/8/2022 12:07 PM
Details	340B ID	Insert	New Registration			4/8/2022 12:07 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2022 12:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2022 12:07 PM
Details	Medicare Provider Number	Insert	New Registration		390079	4/8/2022 12:07 PM
Details	Entity Name	Insert	New Registration		ROBERT PACKER HOSPITAL	4/8/2022 12:07 PM
Details	NOFO Number	Insert	New Registration			4/8/2022 12:07 PM
Details	Program Code	Insert	New Registration		RRC	4/8/2022 12:07 PM
Details	Entity Subname	Insert	New Registration		ROBERT PACKER HOSPITAL TOWANDA CAMP	4/8/2022 12:07 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2022 12:07 PM
Details	State	Insert	New Registration		Pending	4/8/2022 12:07 PM
Dates	Registration Date	Insert	New Registration		4/8/2022 12:07:36 PM	4/8/2022 12:07 PM
Dates	Signed By Date	Insert	New Registration			4/8/2022 12:07 PM
Dates	Start Date	Insert	New Registration			4/8/2022 12:07 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2022 12:07 PM
Terminations	Termination Date	Insert	New Registration			4/8/2022 12:07 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2022 12:07 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2022 12:07 PM