Covered Entity Details

DSH360064M ST. ELIZABETH HEALTH CENTER (Terminated) - information as of 6/9/2025 11:01:58 PM

Main Details

Name

ST. ELIZABETH HEALTH CENTER

Subdivision Name

Youngstown Primary Care - Primary Care

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360064M

Medicare Provider Number

360064

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/14/2022

Participating Start Date

1/1/2023

Participating Approval Date

11/2/2022

Last Recertification Date

Termination Date
Termination Reason

7/1/2023
Hospital Outpatient facility no longer eligible

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

1053 Belmont Avenue
Youngstown, OH 44504

Billing Address

St. Elizabeth Youngstown Inpatient Pharmacy
1044 Belmont Avenue FL 2
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 Inpatient Pharmacy
1044 Belmont Avenue FL 2
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
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	State	Update		To Be Terminated	Terminated	7/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/27/2023 12:00:00 AM	4/26/2023 11:59 AM
Details	State	Update	Termination Request	Active	To Be Terminated	4/26/2023 11:59 AM
Terminations	Termination Date	Update	Termination Request		7/1/2023 12:00:00 AM	4/26/2023 11:59 AM
Terminations	Termination Effective Date	Update	Termination Request		2/27/2023 12:00:00 AM	4/26/2023 11:59 AM
Terminations	Termination Reason	Update	Termination Request		Hospital Outpatient facility no longer eligible	4/26/2023 11:59 AM
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 7:19 AM
Details	340B ID	Update	New Registration		DSH360064M	11/2/2022 7:19 AM
Details	Entity Subname	Update	New Registration	Youngstown Primary Care	Youngstown Primary Care - Primary Care	11/2/2022 7:19 AM
Dates	Participating Approval Date	Update	New Registration		11/2/2022 7:19:44 AM	11/2/2022 7:19 AM
Details	State	Update	New Registration	Pending	Approved	11/2/2022 7:19 AM
Dates	Signed By Date	Update	New Registration		10/14/2022 1:16:54 PM	11/2/2022 7:19 AM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	11/2/2022 7:19 AM
Addresses	Main Address	Insert	New Registration		1053 Belmont Avenue Youngstown, OH 44504	10/14/2022 11:13 AM
Addresses	Billing Address	Insert	New Registration		St. Elizabeth Youngstown Inpatient Pharmacy 1044 Belmont Avenue FL 2 Youngstown, OH 44504	10/14/2022 11:13 AM
Addresses	Shipping Address	Insert	New Registration		St. Elizabeth Youngstown Inpatient Pharmacy 1044 Belmont Avenue FL 2 Youngstown, OH 44504	10/14/2022 11:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2022 11:13 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7645338	10/14/2022 11:13 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/14/2022 11:13 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1548296106	10/14/2022 11:13 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/14/2022 11:13 AM
Contacts	Primary Contact	Insert	New Registration		Baluh, Kyle 340B Program Manager Bon Secours Mercy Health 4402272762	10/14/2022 11:13 AM
Contacts	Authorizing Official	Insert	New Registration		Crawford, Michelle L Market CFO Youngstown Bon Secours Mercy Health 3307188096	10/14/2022 11:13 AM
Details	Assistance Received From Date	Insert	New Registration			10/14/2022 11:13 AM
Details	Assistance Received To Date	Insert	New Registration			10/14/2022 11:13 AM
Details	Last Recertification Date	Insert	New Registration			10/14/2022 11:13 AM
Details	Grant Number	Insert	New Registration			10/14/2022 11:13 AM
Details	340B ID	Insert	New Registration			10/14/2022 11:13 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2022 11:13 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2022 11:13 AM
Details	Medicare Provider Number	Insert	New Registration		360064	10/14/2022 11:13 AM
Details	Entity Name	Insert	New Registration		ST. ELIZABETH HEALTH CENTER	10/14/2022 11:13 AM
Details	NOFO Number	Insert	New Registration			10/14/2022 11:13 AM
Details	Program Code	Insert	New Registration		DSH	10/14/2022 11:13 AM
Details	Entity Subname	Insert	New Registration		Youngstown Primary Care	10/14/2022 11:13 AM
Dates	Participating Approval Date	Insert	New Registration			10/14/2022 11:13 AM
Details	State	Insert	New Registration		Pending	10/14/2022 11:13 AM
Dates	Registration Date	Insert	New Registration		10/14/2022 11:13:37 AM	10/14/2022 11:13 AM
Dates	Signed By Date	Insert	New Registration			10/14/2022 11:13 AM
Dates	Start Date	Insert	New Registration			10/14/2022 11:13 AM
Terminations	Termination Comments	Insert	New Registration			10/14/2022 11:13 AM
Terminations	Termination Date	Insert	New Registration			10/14/2022 11:13 AM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2022 11:13 AM
Terminations	Termination Reason	Insert	New Registration			10/14/2022 11:13 AM