Covered Entity Details

DSH220095Q HENRY HEYWOOD MEMORIAL HOSPITAL (Active) - information as of 6/9/2025 10:58:26 PM

Main Details

Name

HENRY HEYWOOD MEMORIAL HOSPITAL

Subdivision Name

HEYWOOD ENDOCRINOLOGY - Endocrinology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220095Q

Medicare Provider Number

220095

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/14/2025

Participating Start Date

4/1/2025

Participating Approval Date

2/12/2025

Last Recertification Date

Contacts

Authorizing Official

Heywood Healthcare
John Bujak, Chief Financial Officer
(978) 630-6202

Primary Contact

Heywood Healthcare
Lori Doucette, 340B Program Director
(978) 630-6161 Ext: 2076298672

Addresses

Street Address

250 GREEN ST
STE 104
GARDNER, MA 01440-1377

Billing Address

Henry Heywood Memorial Hospital
242 Green Street
Gardner, MA 01440

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 10/1/2023, terminated 4/1/2024. Reinstated 4/1/2025.	02/12/2025

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
MA	1200739	1205823879

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
DSH220095A	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	WINCHENDON HEALTH CENTER	55 HOSPITAL DR	WINCHENDON	MA	Active
DSH220095B	Child	DSH	HEYWOOD HOSPITAL	HEYWOOD REHAB CENTER	69 PEARSON BLVD	GARDNER	MA	Terminated
DSH220095C	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	HENRY HEYWOOD MEMORIAL HOSPITAL - Orthopedics	250 Green St	GARDNER	MA	Active
DSH220095D	Child	DSH	HEYWOOD HOSPITAL	HEYWOOD CENTER OF BARIATRICS AND WEIGHT LOSS	250 GREEN ST	GARDNER	MA	Terminated
DSH220095E	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	HENRY HEYWOOD MEMORIAL HOSPITAL - Urology	250 GREEN ST	GARDNER	MA	Active
DSH220095F	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	HENRY HEYWOOD MEMORIAL HOSPITAL - Pediatrics	250 GREEN ST	GARDNER	MA	Active
DSH220095G	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	Heywood Health Center for Women	250 GREEN ST	GARDNER	MA	Active
DSH220095H	Child	DSH	HEYWOOD HOSPITAL	Heywood Psych - Psychiatry	259 Green Street	Gardner	MA	Terminated
DSH220095J	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	Heywood Rheumatology	250 Green Street	Gardner	MA	Active
DSH220095K	Child	DSH	HEYWOOD HOSPITAL	HEYWOOD SURGICAL ASSOCIATES	250 Green Street	Gardner	MA	Terminated
DSH220095L	Child	DSH	HEYWOOD HOSPITAL	Heywood Neurology - Neurology	250 Green Street	Gardner	MA	Terminated
DSH220095M	Child	DSH	HEYWOOD HOSPITAL	HEYWOOD PULMONARY MEDICINE - Pulmonology	250 GREEN ST	GARDNER	MA	Terminated
DSH220095N	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	Heywood Gastroenterology	250 Green Street	Gardner	MA	Active
DSH220095P	Child	DSH	HEYWOOD HOSPITAL	Heywood Infectious Disease - Infectious Disease	250 Green Street	Gardner	MA	Terminated
DSH220095Q	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	HEYWOOD ENDOCRINOLOGY - Endocrinology	250 GREEN ST	GARDNER	MA	Active
DSH220095R	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	Encompass Primary Care - Primary Care	250 Green Street	GARDNER	MA	Active
DSH220095S	Child	DSH	HENRY HEYWOOD MEMORIAL HOSPITAL	Heywood Nutrtion - Nutrition	250 GREEN STREET	Gardner	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Addresses	Billing Address	Insert	Reinstatement		Henry Heywood Memorial Hospital 242 Green Street Gardner, MA 01440	2/12/2025 10:49 AM
Contacts	Authorizing Official	Update	Reinstatement	Sullivan, Tom CFO Heywood Hospital 9786306157	Bujak, John Chief Financial Officer Heywood Healthcare 9786306202	2/12/2025 10:49 AM
Contacts	Signed By	Update	Reinstatement	Sullivan, Tom CFO Heywood Hospital 9786306157	Bujak, John Chief Financial Officer Heywood Healthcare 9786306202	2/12/2025 10:49 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	2/29/2024 12:00:00 AM		2/12/2025 10:49 AM
Details	Entity Name	Update	Reinstatement	HEYWOOD HOSPITAL	HENRY HEYWOOD MEMORIAL HOSPITAL	2/12/2025 10:49 AM
Dates	Participating Approval Date	Update	Reinstatement	8/1/2023 8:43:50 AM	2/12/2025 10:49:34 AM	2/12/2025 10:49 AM
Details	State	Update	Reinstatement	Terminated	Approved	2/12/2025 10:49 AM
Dates	Registration Date	Update	Reinstatement	7/21/2023 2:10:10 PM	1/14/2025 3:29:03 PM	2/12/2025 10:49 AM
Dates	Signed By Date	Update	Reinstatement	7/26/2023 4:32:51 PM	2/7/2025 9:04:07 AM	2/12/2025 10:49 AM
Dates	Start Date	Update	Reinstatement	10/1/2023 12:00:00 AM	4/1/2025 12:00:00 AM	2/12/2025 10:49 AM
Terminations	Termination Date	Update	Reinstatement	4/1/2024 12:00:00 AM		2/12/2025 10:49 AM
Terminations	Termination Effective Date	Update	Reinstatement	2/29/2024 12:00:00 AM		2/12/2025 10:49 AM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		2/12/2025 10:49 AM
Details	Comments Public	Insert	Reinstatement		Participated starting 10/1/2023, terminated 4/1/2024. Reinstated 4/1/2025.	2/12/2025 8:55 AM
Contacts	Primary Contact	Update	Profile Change Request	Doucette, Lori Interim 340B Program Director Heywood Healthcare 9786305576	Doucette, Lori 340B Program Director Heywood Healthcare 9786306161-2076298672	8/27/2024 3:56 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/29/2024 12:00:00 AM	3/1/2024 11:04 AM
Details	State	Update	Termination Request	Active	To Be Terminated	3/1/2024 11:04 AM
Terminations	Termination Date	Update	Termination Request		4/1/2024 12:00:00 AM	3/1/2024 11:04 AM
Terminations	Termination Effective Date	Update	Termination Request		2/29/2024 12:00:00 AM	3/1/2024 11:04 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	3/1/2024 11:04 AM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Sullivan, Tom CFO Heywood Hospital 9786306157	8/1/2023 8:43 AM
Details	340B ID	Update	New Registration		DSH220095Q	8/1/2023 8:43 AM
Details	Entity Name	Update	New Registration	HENRY HEYWOOD MEMORIAL HOSPITAL	HEYWOOD HOSPITAL	8/1/2023 8:43 AM
Details	Entity Subname	Update	New Registration	HEYWOOD ENDOCRINOLOGY	HEYWOOD ENDOCRINOLOGY - Endocrinology	8/1/2023 8:43 AM
Dates	Participating Approval Date	Update	New Registration		8/1/2023 8:43:50 AM	8/1/2023 8:43 AM
Details	State	Update	New Registration	Pending	Approved	8/1/2023 8:43 AM
Dates	Signed By Date	Update	New Registration		7/26/2023 4:32:51 PM	8/1/2023 8:43 AM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	8/1/2023 8:43 AM
Addresses	Main Address	Insert	New Registration		250 GREEN ST STE 104 GARDNER, MA 01440-1377	7/21/2023 2:10 PM
Addresses	Billing Address	Insert	New Registration		Henry Heywood Memorial Hospital 242 Green Street Gardner, MA 01440	7/21/2023 2:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/21/2023 2:10 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1200739	7/21/2023 2:10 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MA	7/21/2023 2:10 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1205823879	7/21/2023 2:10 PM
Medicaid Billing	NPI: State	Insert	New Registration		MA	7/21/2023 2:10 PM
Contacts	Authorizing Official	Insert	New Registration		Sullivan, Tom CFO Heywood Hospital 9786306157	7/21/2023 2:10 PM
Contacts	Primary Contact	Insert	New Registration		Doucette, Lori Interim 340B Program Director Heywood Healthcare 9786305576	7/21/2023 2:10 PM
Details	Assistance Received From Date	Insert	New Registration			7/21/2023 2:10 PM
Details	Assistance Received To Date	Insert	New Registration			7/21/2023 2:10 PM
Details	Last Recertification Date	Insert	New Registration			7/21/2023 2:10 PM
Details	Grant Number	Insert	New Registration			7/21/2023 2:10 PM
Details	340B ID	Insert	New Registration			7/21/2023 2:10 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/21/2023 2:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/21/2023 2:10 PM
Details	Medicare Provider Number	Insert	New Registration		220095	7/21/2023 2:10 PM
Details	Entity Name	Insert	New Registration		HENRY HEYWOOD MEMORIAL HOSPITAL	7/21/2023 2:10 PM
Details	NOFO Number	Insert	New Registration			7/21/2023 2:10 PM
Details	Program Code	Insert	New Registration		DSH	7/21/2023 2:10 PM
Details	Entity Subname	Insert	New Registration		HEYWOOD ENDOCRINOLOGY	7/21/2023 2:10 PM
Dates	Participating Approval Date	Insert	New Registration			7/21/2023 2:10 PM
Details	State	Insert	New Registration		Pending	7/21/2023 2:10 PM
Dates	Registration Date	Insert	New Registration		7/21/2023 2:10:10 PM	7/21/2023 2:10 PM
Dates	Signed By Date	Insert	New Registration			7/21/2023 2:10 PM
Dates	Start Date	Insert	New Registration			7/21/2023 2:10 PM
Terminations	Termination Comments	Insert	New Registration			7/21/2023 2:10 PM
Terminations	Termination Date	Insert	New Registration			7/21/2023 2:10 PM
Terminations	Termination Effective Date	Insert	New Registration			7/21/2023 2:10 PM
Terminations	Termination Reason	Insert	New Registration			7/21/2023 2:10 PM