Covered Entity Details

PED073300-09 CONNECTICUT CHILDREN'S MEDICAL CENTER (Active) - information as of 4/30/2025 10:53:49 PM

Main Details

Name

CONNECTICUT CHILDREN'S MEDICAL CENTER

Subdivision Name

CONNECTICUT CHILDREN'S MEDICAL CENT - Connecticut Children's Medical Center - Endocrinology Westport

Type

Children's Hospital

Rural

340B ID

PED073300-09

Medicare Provider Number

073300

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/11/2023

Participating Start Date

7/1/2023

Participating Approval Date

5/10/2023

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

CT Children's
Robert Elijah Duncan, Executive Vice President & Chief Operating Officer
(860) 545-8648

Primary Contact

Connecticut Children's Medical Center
Heather Hipsky, Pharmacy Procurement Manager
(860) 837-5116

Addresses

Street Address

191 POST RD W
WESTPORT, CT 06880-4625

Billing Address
Same as Street Address

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
CT	004159978	1134271661

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
PED073300-01	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	Connecticut Children's Medical Center Infusion Center - Infusion Center	10 Birdseye Rd	Farmington	CT	Active
PED073300-02	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	CONNECTICUT CHILDREN'S MEDICAL CENT - Connecticut Children's Medical Center Endocrinology Hartford	85 SEYMOUR ST	HARTFORD	CT	Active
PED073300-03	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	CONNECTICUT CHILDREN'S MEDICAL CENT - Connecticut Children's Medical Center Endocrinology Shelton	4 CORPORATE DR	SHELTON	CT	Active
PED073300-04	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	CONNECTICUT CHILDRENS MEDICAL CENTE - Connecticut Children's Medical Center Endocrinology Farmington	505 FARMINGTON AVE	FARMINGTON	CT	Active
PED073300-05	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	CONNECTICUT CHILDREN'S MEDICAL CENT - Connecticut Children's Medical Center Endocrinology Danbury	105-A NEWTOWN RD	DANBURY	CT	Active
PED073300-06	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	CONNECTICUT CHILDREN'S MEDICAL CENT - Connecticut Children's Medical Center Endocrinology Glastonbury	310 WESTERN BLVD	GLASTONBURY	CT	Active
PED073300-07	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	CONNECTICUT CHILDRENS MEDICAL CENTE - Ambulatory Surgery Center	505 FARMINGTON AVE	FARMINGTON	CT	Active
PED073300-08	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	CONNECTICUT CHILDREN'S MEDICAL CENT - Connecticut Children's Medical Center - Infusion Center Westport	191 POST RD W	WESTPORT	CT	Active
PED073300-09	Child	PED	CONNECTICUT CHILDREN'S MEDICAL CENTER	CONNECTICUT CHILDREN'S MEDICAL CENT - Connecticut Children's Medical Center - Endocrinology Westport	191 POST RD W	WESTPORT	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/17/2023 2:11:25 PM	8/16/2024 9:40:36 AM	8/16/2024 9:40 AM
Details	Last Recertification Date	Update	Recertification		8/17/2023 2:11:25 PM	8/17/2023 2:11 PM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Duncan, Robert Elijah Executive Vice President & Chief Operating Officer CT Children's 8605458648	5/10/2023 1:04 PM
Details	340B ID	Update	New Registration		PED073300-09	5/10/2023 1:04 PM
Details	Entity Name	Update	New Registration	CONNECTICUT CHILDRENS MEDICAL CENTER	CONNECTICUT CHILDREN'S MEDICAL CENTER	5/10/2023 1:04 PM
Details	Entity Subname	Update	New Registration	CONNECTICUT CHILDREN'S MEDICAL CENT	CONNECTICUT CHILDREN'S MEDICAL CENT - Connecticut Children's Medical Center - Endocrinology Westport	5/10/2023 1:04 PM
Dates	Participating Approval Date	Update	New Registration		5/10/2023 1:04:44 PM	5/10/2023 1:04 PM
Details	State	Update	New Registration	Pending	Approved	5/10/2023 1:04 PM
Dates	Signed By Date	Update	New Registration		5/1/2023 11:37:17 AM	5/10/2023 1:04 PM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	5/10/2023 1:04 PM
Addresses	Main Address	Insert	New Registration		191 POST RD W WESTPORT, CT 06880-4625	4/11/2023 1:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2023 1:23 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004159978	4/11/2023 1:23 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/11/2023 1:23 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1134271661	4/11/2023 1:23 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/11/2023 1:23 PM
Contacts	Primary Contact	Insert	New Registration		Hipsky, Heather Pharmacy Procurement Manager Connecticut Children's Medical Center 8608375116	4/11/2023 1:23 PM
Contacts	Authorizing Official	Insert	New Registration		Duncan, Robert Elijah Executive Vice President & Chief Operating Officer CT Children's 8605458648	4/11/2023 1:23 PM
Details	Assistance Received From Date	Insert	New Registration			4/11/2023 1:23 PM
Details	Assistance Received To Date	Insert	New Registration			4/11/2023 1:23 PM
Details	Last Recertification Date	Insert	New Registration			4/11/2023 1:23 PM
Details	Grant Number	Insert	New Registration			4/11/2023 1:23 PM
Details	340B ID	Insert	New Registration			4/11/2023 1:23 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2023 1:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2023 1:23 PM
Details	Medicare Provider Number	Insert	New Registration		073300	4/11/2023 1:23 PM
Details	Entity Name	Insert	New Registration		CONNECTICUT CHILDRENS MEDICAL CENTER	4/11/2023 1:23 PM
Details	NOFO Number	Insert	New Registration			4/11/2023 1:23 PM
Details	Program Code	Insert	New Registration		PED	4/11/2023 1:23 PM
Details	Entity Subname	Insert	New Registration		CONNECTICUT CHILDREN'S MEDICAL CENT	4/11/2023 1:23 PM
Dates	Participating Approval Date	Insert	New Registration			4/11/2023 1:23 PM
Details	State	Insert	New Registration		Pending	4/11/2023 1:23 PM
Dates	Registration Date	Insert	New Registration		4/11/2023 1:23:24 PM	4/11/2023 1:23 PM
Dates	Signed By Date	Insert	New Registration			4/11/2023 1:23 PM
Dates	Start Date	Insert	New Registration			4/11/2023 1:23 PM
Terminations	Termination Comments	Insert	New Registration			4/11/2023 1:23 PM
Terminations	Termination Date	Insert	New Registration			4/11/2023 1:23 PM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2023 1:23 PM
Terminations	Termination Reason	Insert	New Registration			4/11/2023 1:23 PM