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SCH330157-05 SAMARITAN MEDICAL CENTER (Terminated)
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Main Details
Name
SAMARITAN MEDICAL CENTER
Subdivision Name
SAMARITAN MEDICAL CENTER - Samaritan Health LaCona Clinic
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH330157-05
Medicare Provider Number
330157
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/11/2017
Participating Start Date
1/1/2018
Participating Approval Date
11/15/2017
Last Recertification Date
8/22/2019
Termination Date
Termination Reason
10/1/2020
Change of covered entity type
Contacts
Authorizing Official
Samaritan Medical Center
Maxine A Briggs, VP Of Fiscal Services/Chief Financial Officer
(315) 755-3605
Primary Contact
Samaritan Medical Center
Krista Ann Krull-Goss, Director of Pharmacy
(315) 785-4248
Addresses
Street Address
3 DEMOTT ST
LACONA, NY 13083
Billing Address
Samaritan Health LaCona Clinic
830 Washington Street
Watertown, NY 13601
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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