Covered Entity Details

RRC070017-01 MIDSTATE MEDICAL CENTER (Approved) - information as of 5/2/2025 10:39:51 PM

Main Details

Name

MIDSTATE MEDICAL CENTER

Subdivision Name

MMC MEDIQUICK MERIDEN - urgent care

Type

Rural Referral Center

Rural

Yes

340B ID

RRC070017-01

Medicare Provider Number

070017

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/1/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/15/2025

Last Recertification Date

Contacts

Authorizing Official

Hartford Healthcare
Joseph Del Mastro, HHC Reg VP Finance Central
(959) 236-3295

Primary Contact

Hartford HealthCare
Elyse Anna Lanteigne, 340B Program Manager
(860) 972-5030

Addresses

Street Address

61 Pomeroy Avenue
Meriden, CT 06450

Billing Address

Midstate Medical Center
PO BOX 5037
Attn: accounts payable
Hartford, CT 06102

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating Start Date 6/5/2023, Termination 4/1/2025, Reinstatement 7/1/2025	04/02/2025

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	4041778,4025078	1669524187,1427007848,1316022718

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
RRC070017-01	Child	RRC	MIDSTATE MEDICAL CENTER	MMC MEDIQUICK MERIDEN - urgent care	61 Pomeroy Avenue	Meriden	CT	Approved
RRC070017-02	Child	RRC	MIDSTATE MEDICAL CENTER	MMC INFECTIOUS DS MRDN - Infectious Disease	61 Pomeroy Avenue	Meriden	CT	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Insert	Reinstatement		Midstate Medical Center PO BOX 5037 Attn: accounts payable Hartford, CT 06102	4/15/2025 10:50 AM
Contacts	Signed By	Update	Reinstatement	Curtin, Sean Michael Vice President, Finance, Hartford Region Hartford Healthcare 8605450585	Del Mastro, Joseph HHC Reg VP Finance Central Hartford Healthcare 9592363295	4/15/2025 10:50 AM
Contacts	Primary Contact	Update	Reinstatement	Sweeney, Elyse A System 340B Program Manager Hartford Healthcare 8609725030	Lanteigne, Elyse Anna 340B Program Manager Hartford HealthCare 8609725030	4/15/2025 10:50 AM
Details	Last Recertification Date	Update	Reinstatement	8/27/2024 8:07:40 PM		4/15/2025 10:50 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	2/27/2025 12:00:00 AM		4/15/2025 10:50 AM
Dates	Participating Approval Date	Update	Reinstatement	6/5/2023 7:26:42 AM	4/15/2025 10:50:19 AM	4/15/2025 10:50 AM
Details	State	Update	Reinstatement	Terminated	Approved	4/15/2025 10:50 AM
Dates	Registration Date	Update	Reinstatement	6/1/2023 9:35:49 AM	4/1/2025 10:01:36 AM	4/15/2025 10:50 AM
Dates	Signed By Date	Update	Reinstatement	6/1/2023 2:43:05 PM	4/1/2025 1:13:05 PM	4/15/2025 10:50 AM
Dates	Start Date	Update	Reinstatement	6/5/2023 12:00:00 AM	7/1/2025 12:00:00 AM	4/15/2025 10:50 AM
Terminations	Termination Comments	Update	Reinstatement	DSH % fell below the required threshold. MCR was filed at 2/2/25 at 9:24am with a documented 7.81%.		4/15/2025 10:50 AM
Terminations	Termination Date	Update	Reinstatement	4/1/2025 12:00:00 AM		4/15/2025 10:50 AM
Terminations	Termination Effective Date	Update	Reinstatement	2/28/2025 12:00:00 AM		4/15/2025 10:50 AM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		4/15/2025 10:50 AM
Details	Comments Public	Insert	Reinstatement		Participating Start Date 6/5/2023, Termination 4/1/2025, Reinstatement 7/1/2025	4/2/2025 8:16 AM
Details	State	Update		To Be Terminated	Terminated	4/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/27/2025 12:00:00 AM	3/3/2025 11:52 AM
Details	State	Update	Termination Request	Active	To Be Terminated	3/3/2025 11:52 AM
Terminations	Termination Comments	Update	Termination Request		DSH % fell below the required threshold. MCR was filed at 2/2/25 at 9:24am with a documented 7.81%.	3/3/2025 11:52 AM
Terminations	Termination Date	Update	Termination Request		4/1/2025 12:00:00 AM	3/3/2025 11:52 AM
Terminations	Termination Effective Date	Update	Termination Request		2/28/2025 12:00:00 AM	3/3/2025 11:52 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	3/3/2025 11:52 AM
Contacts	Signed By	Update	Profile Change Request	Curtin, Sean Michael Vice President, Finance, Central Region Hartford Healthcare 8602245194	Curtin, Sean Michael Vice President, Finance, Hartford Region Hartford Healthcare 8605450585	12/26/2024 7:46 AM
Details	Last Recertification Date	Update	Recertification	8/28/2023 8:56:59 AM	8/27/2024 8:07:40 PM	8/27/2024 8:07 PM
Contacts	Authorizing Official	Update	Change Request	Curtin, Sean Michael Vice President, Finance, Central Region Hartford Healthcare 8602245194	Del Mastro, Joseph HHC Reg VP Finance Central Hartford Healthcare 9592363295	1/12/2024 2:16 PM
Details	Last Recertification Date	Update	Recertification		8/28/2023 8:56:59 AM	8/28/2023 8:56 AM
Details	State	Update	OPA Edit	Approved	Active	6/5/2023 9:47 AM
Dates	Start Date	Update	OPA Edit	7/1/2023 12:00:00 AM	6/5/2023 12:00:00 AM	6/5/2023 9:47 AM
Contacts	Signed By	Insert	New Registration		Curtin, Sean Michael Vice President, Finance, Central Region Hartford Healthcare 8602245194	6/5/2023 7:26 AM
Details	340B ID	Update	New Registration		RRC070017-01	6/5/2023 7:26 AM
Details	Entity Subname	Update	New Registration	MMC MEDIQUICK MERIDEN	MMC MEDIQUICK MERIDEN - urgent care	6/5/2023 7:26 AM
Dates	Participating Approval Date	Update	New Registration		6/5/2023 7:26:42 AM	6/5/2023 7:26 AM
Details	State	Update	New Registration	Pending	Approved	6/5/2023 7:26 AM
Dates	Signed By Date	Update	New Registration		6/1/2023 2:43:05 PM	6/5/2023 7:26 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	6/5/2023 7:26 AM
Addresses	Main Address	Insert	New Registration		61 Pomeroy Avenue Meriden, CT 06450	6/1/2023 9:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 9:35 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4041778	6/1/2023 9:35 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	6/1/2023 9:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	6/1/2023 9:35 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4025078	6/1/2023 9:35 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	6/1/2023 9:35 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1669524187	6/1/2023 9:35 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	6/1/2023 9:35 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427007848	6/1/2023 9:35 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	6/1/2023 9:35 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316022718	6/1/2023 9:35 AM
Medicaid Billing	NPI: State	Insert	New Registration		CT	6/1/2023 9:35 AM
Contacts	Primary Contact	Insert	New Registration		Sweeney, Elyse A System 340B Program Manager Hartford Healthcare 8609725030	6/1/2023 9:35 AM
Contacts	Authorizing Official	Insert	New Registration		Curtin, Sean Michael Vice President, Finance, Central Region Hartford Healthcare 8602245194	6/1/2023 9:35 AM
Details	Assistance Received From Date	Insert	New Registration			6/1/2023 9:35 AM
Details	Assistance Received To Date	Insert	New Registration			6/1/2023 9:35 AM
Details	Last Recertification Date	Insert	New Registration			6/1/2023 9:35 AM
Details	Grant Number	Insert	New Registration			6/1/2023 9:35 AM
Details	340B ID	Insert	New Registration			6/1/2023 9:35 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			6/1/2023 9:35 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			6/1/2023 9:35 AM
Details	Medicare Provider Number	Insert	New Registration		070017	6/1/2023 9:35 AM
Details	Entity Name	Insert	New Registration		MIDSTATE MEDICAL CENTER	6/1/2023 9:35 AM
Details	NOFO Number	Insert	New Registration			6/1/2023 9:35 AM
Details	Program Code	Insert	New Registration		RRC	6/1/2023 9:35 AM
Details	Entity Subname	Insert	New Registration		MMC MEDIQUICK MERIDEN	6/1/2023 9:35 AM
Dates	Participating Approval Date	Insert	New Registration			6/1/2023 9:35 AM
Details	State	Insert	New Registration		Pending	6/1/2023 9:35 AM
Dates	Registration Date	Insert	New Registration		6/1/2023 9:35:49 AM	6/1/2023 9:35 AM
Dates	Signed By Date	Insert	New Registration			6/1/2023 9:35 AM
Dates	Start Date	Insert	New Registration			6/1/2023 9:35 AM
Terminations	Termination Comments	Insert	New Registration			6/1/2023 9:35 AM
Terminations	Termination Date	Insert	New Registration			6/1/2023 9:35 AM
Terminations	Termination Effective Date	Insert	New Registration			6/1/2023 9:35 AM
Terminations	Termination Reason	Insert	New Registration			6/1/2023 9:35 AM