Covered Entity Details

DSH360064E MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL (ToBeTerminated) - information as of 5/1/2025 11:42:45 PM

Main Details

Name

MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL

Subdivision Name

Austintown Medical Center - Emergency

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360064E

Medicare Provider Number

360064

Outpatient Facility Provider Number

Additional Details

Current Program Status

ToBeTerminated

Registration Date

10/14/2022

Participating Start Date

1/1/2023

Participating Approval Date

11/2/2022

Last Recertification Date

8/27/2024

Termination Date
Termination Reason

7/1/2025
Change of covered entity type

Contacts

Authorizing Official

Bon Secours Mercy Health
Michelle L Crawford, Market CFO Youngstown
(330) 718-8096

Primary Contact

Bon Secours Mercy Health
Kyle Baluh, Director, 340B Programs
(440) 227-2762

Addresses

Street Address

6252 Mahoning Avenue
Austintown, OH 44515

Billing Address

ST. ELIZABETH YOUNGSTOWN HOSPITAL
1044 Belmont Avenue
Youngstown, OH 44504

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
OH	7645338	1548296106

Shipping Addresses

Shipping Address 1

ST. ELIZABETH YOUNGSTOWN HOSPITAL MAIN CAMPUS - PHARMACY
1044 Belmont Avenue
Youngstown, OH 44504

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
DSH360064A	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	MH-YOUNGST PEDI,WOMEN,SURG,INTER, P - Internal Medicine	1001 Covington Street	Youngstown	OH	ToBeTerminated
DSH360064B	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	MH-YOUNGST PEDI,WOMEN,SURG,INTER, P - Surgery	1001 Covington Street	Youngstown	OH	ToBeTerminated
DSH360064C	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	MH-YOUNGST PEDI,WOMEN,SURG,INTER, P - Pulmonary	1001 Covington Street	Youngstown	OH	ToBeTerminated
DSH360064D	Child	DSH	ST. ELIZABETH HEALTH CENTER	Ambulatory Care Center - Women's Center	1001 Covington Street	Youngstown	OH	Terminated
DSH360064E	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	Austintown Medical Center - Emergency	6252 Mahoning Avenue	Austintown	OH	ToBeTerminated
DSH360064F	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	Austintown Medical Center - MRI	6252 Mahoning Avenue	Austintown	OH	ToBeTerminated
DSH360064G	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	Austintown Medical Center - CT	6252 Mahoning Avenue	Austintown	OH	ToBeTerminated
DSH360064H	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	Austintown Medical Center - Diagnostic Radiology	6252 Mahoning Avenue	Austintown	OH	ToBeTerminated
DSH360064J	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	Heart and Vascular Institute - Poland Cardiac Imaging	715 E Western Reserve Road	Poland	OH	ToBeTerminated
DSH360064K	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	Heart and Vascular Institute - Belmont Youngstown Cardiac Imaging	1001 Belmont Avenue	Youngstown	OH	ToBeTerminated
DSH360064L	Child	DSH	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	Heart and Vascular Institute - Eastland Warren Cardiac Imaging	627 Eastland Avenue SE STE 101	Warren	OH	ToBeTerminated
DSH360064M	Child	DSH	ST. ELIZABETH HEALTH CENTER	Youngstown Primary Care - Primary Care	1053 Belmont Avenue	Youngstown	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/22/2025 6:51 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	4/22/2025 6:51 AM
Terminations	Termination Date	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/22/2025 6:51 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		7/1/2025 12:00:00 AM	4/22/2025 6:51 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	4/22/2025 6:51 AM
Contacts	Primary Contact	Update	Profile Change Request	Baluh, Kyle 340B Program Manager Bon Secours Mercy Health 4402272762	Baluh, Kyle Director, 340B Programs Bon Secours Mercy Health 4402272762	11/18/2024 9:38 AM
Details	Last Recertification Date	Update	Recertification	8/29/2023 2:21:07 PM	8/27/2024 1:11:11 PM	8/27/2024 1:11 PM
Addresses	Billing Address	Update	Change Request	St. Elizabeth Youngstown Inpatient Pharmacy 1044 Belmont Avenue FL 2 Youngstown, OH 44504	ST. ELIZABETH YOUNGSTOWN HOSPITAL 1044 Belmont Avenue Youngstown, OH 44504	6/6/2024 8:55 AM
Addresses	Shipping Address	Update	Change Request	St. Elizabeth Youngstown Inpatient Pharmacy 1044 Belmont Avenue FL 2 Youngstown, OH 44504	ST. ELIZABETH YOUNGSTOWN HOSPITAL MAIN CAMPUS - PHARMACY 1044 Belmont Avenue Youngstown, OH 44504	6/6/2024 8:55 AM
Details	Entity Name	Update	Change Request	ST. ELIZABETH HEALTH CENTER	MERCY HEALTH - ST. ELIZABETH YOUNGSTOWN HOSPITAL	6/6/2024 8:55 AM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Cancel Termination Request	7/1/2024 12:00:00 AM		6/4/2024 7:03 AM
Details	State	Update	OPA Cancel Termination Request	To Be Terminated	Active	6/4/2024 7:03 AM
Terminations	Termination Date	Update	OPA Cancel Termination Request	7/1/2024 12:00:00 AM		6/4/2024 7:03 AM
Terminations	Termination Effective Date	Update	OPA Cancel Termination Request	7/1/2024 12:00:00 AM		6/4/2024 7:03 AM
Terminations	Termination Reason	Update	OPA Cancel Termination Request	Change of covered entity type		6/4/2024 7:03 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		7/1/2024 12:00:00 AM	4/30/2024 12:49 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	4/30/2024 12:49 PM
Terminations	Termination Date	Update	Hospital Type Change Request		7/1/2024 12:00:00 AM	4/30/2024 12:49 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		7/1/2024 12:00:00 AM	4/30/2024 12:49 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	4/30/2024 12:49 PM
Details	Last Recertification Date	Update	Recertification		8/29/2023 2:21:07 PM	8/29/2023 2:21 PM
Details	State	Update		Approved	Active	1/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Crawford, Michelle L Market CFO Youngstown Bon Secours Mercy Health 3307188096	11/2/2022 7:16 AM
Details	340B ID	Update	New Registration		DSH360064E	11/2/2022 7:16 AM
Details	Entity Subname	Update	New Registration	Austintown Medical Center	Austintown Medical Center - Emergency	11/2/2022 7:16 AM
Dates	Participating Approval Date	Update	New Registration		11/2/2022 7:16:09 AM	11/2/2022 7:16 AM
Details	State	Update	New Registration	Pending	Approved	11/2/2022 7:16 AM
Dates	Signed By Date	Update	New Registration		10/14/2022 1:30:19 PM	11/2/2022 7:16 AM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	11/2/2022 7:16 AM
Addresses	Main Address	Insert	New Registration		6252 Mahoning Avenue Austintown, OH 44515	10/14/2022 10:17 AM
Addresses	Billing Address	Insert	New Registration		St. Elizabeth Youngstown Inpatient Pharmacy 1044 Belmont Avenue FL 2 Youngstown, OH 44504	10/14/2022 10:17 AM
Addresses	Shipping Address	Insert	New Registration		St. Elizabeth Youngstown Inpatient Pharmacy 1044 Belmont Avenue FL 2 Youngstown, OH 44504	10/14/2022 10:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2022 10:17 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7645338	10/14/2022 10:17 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/14/2022 10:17 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1548296106	10/14/2022 10:17 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/14/2022 10:17 AM
Contacts	Primary Contact	Insert	New Registration		Baluh, Kyle 340B Program Manager Bon Secours Mercy Health 4402272762	10/14/2022 10:17 AM
Contacts	Authorizing Official	Insert	New Registration		Crawford, Michelle L Market CFO Youngstown Bon Secours Mercy Health 3307188096	10/14/2022 10:17 AM
Details	Assistance Received From Date	Insert	New Registration			10/14/2022 10:17 AM
Details	Assistance Received To Date	Insert	New Registration			10/14/2022 10:17 AM
Details	Last Recertification Date	Insert	New Registration			10/14/2022 10:17 AM
Details	Grant Number	Insert	New Registration			10/14/2022 10:17 AM
Details	340B ID	Insert	New Registration			10/14/2022 10:17 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2022 10:17 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2022 10:17 AM
Details	Medicare Provider Number	Insert	New Registration		360064	10/14/2022 10:17 AM
Details	Entity Name	Insert	New Registration		ST. ELIZABETH HEALTH CENTER	10/14/2022 10:17 AM
Details	NOFO Number	Insert	New Registration			10/14/2022 10:17 AM
Details	Program Code	Insert	New Registration		DSH	10/14/2022 10:17 AM
Details	Entity Subname	Insert	New Registration		Austintown Medical Center	10/14/2022 10:17 AM
Dates	Participating Approval Date	Insert	New Registration			10/14/2022 10:17 AM
Details	State	Insert	New Registration		Pending	10/14/2022 10:17 AM
Dates	Registration Date	Insert	New Registration		10/14/2022 10:17:08 AM	10/14/2022 10:17 AM
Dates	Signed By Date	Insert	New Registration			10/14/2022 10:17 AM
Dates	Start Date	Insert	New Registration			10/14/2022 10:17 AM
Terminations	Termination Comments	Insert	New Registration			10/14/2022 10:17 AM
Terminations	Termination Date	Insert	New Registration			10/14/2022 10:17 AM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2022 10:17 AM
Terminations	Termination Reason	Insert	New Registration			10/14/2022 10:17 AM