Covered Entity Details

DSH360218C LICKING MEMORIAL HOSPITAL (Active) - information as of 5/14/2025 10:57:42 PM

Main Details

Name

LICKING MEMORIAL HOSPITAL

Subdivision Name

LMH RHEUMATOLOGY CLINIC - Rheumatology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH360218C

Medicare Provider Number

360218

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/10/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/12/2024

Last Recertification Date

Contacts

Authorizing Official

Licking Memorial Hospital
Cynthia L. Webster, Chief Financial Officer
(220) 564-4518

Primary Contact

Licking Memorial hospital
Robert Merrill Fish, Jr., Pharmacy Business Manager
(220) 564-4598

Addresses

Street Address

1902 TAMARACK RD
NEWARK, OH 43055-2303

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
OH	5172389	1568446755

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
DSH360218A	Child	DSH	LICKING MEMORIAL HOSPITAL	LICKING MEMORIAL HOSPITAL TAMARACK - Outpatient Surgery	2000 TAMARACK RD	NEWARK	OH	Active
DSH360218B	Child	DSH	LICKING MEMORIAL HOSPITAL	Licking Memorial Hospital Anticoagulation Clinic - Medication Therapy Clinic (Anticoagulation Clinic)	88 McMillen Drive	Newark	OH	Active
DSH360218C	Child	DSH	LICKING MEMORIAL HOSPITAL	LMH RHEUMATOLOGY CLINIC - Rheumatology	1902 TAMARACK RD	NEWARK	OH	Active
DSH360218D	Child	DSH	LICKING MEMORIAL HOSPITAL	LMH DERMATOLOGY CLINIC - WEST MAIN - Dermatology	1717 W MAIN ST STE 204	NEWARK	OH	Active
DSH360218E	Child	DSH	LICKING MEMORIAL HOSPITAL	Licking Memorial Hospital Pain Management - Pain Clinic	2000 Tamarack Road	Newark	OH	Active
DSH360218F	Child	DSH	LICKING MEMORIAL HOSPITAL	Licking Memorial Hospital Wound Clinic - Wound Clinic	2000 Tamarack Road	Newark	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Webster, Cynthia L. Chief Financial Officer Licking Memorial Hospital 2205644518	8/12/2024 8:14 AM
Details	340B ID	Update	New Registration		DSH360218C	8/12/2024 8:14 AM
Details	Entity Subname	Update	New Registration	LMH RHEUMATOLOGY CLINIC	LMH RHEUMATOLOGY CLINIC - Rheumatology	8/12/2024 8:14 AM
Dates	Participating Approval Date	Update	New Registration		8/12/2024 8:14:53 AM	8/12/2024 8:14 AM
Details	State	Update	New Registration	Pending	Approved	8/12/2024 8:14 AM
Dates	Signed By Date	Update	New Registration		8/7/2024 1:02:43 PM	8/12/2024 8:14 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/12/2024 8:14 AM
Addresses	Main Address	Insert	New Registration		1902 TAMARACK RD NEWARK, OH 43055-2303	7/10/2024 5:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/10/2024 5:33 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		5172389	7/10/2024 5:33 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	7/10/2024 5:33 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1568446755	7/10/2024 5:33 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/10/2024 5:33 PM
Contacts	Primary Contact	Insert	New Registration		Fish, Jr., Robert Merrill Pharmacy Business Manager Licking Memorial hospital 2205644598	7/10/2024 5:33 PM
Contacts	Authorizing Official	Insert	New Registration		Webster, Cynthia L. Chief Financial Officer Licking Memorial Hospital 2205644518	7/10/2024 5:33 PM
Details	Assistance Received From Date	Insert	New Registration			7/10/2024 5:33 PM
Details	Assistance Received To Date	Insert	New Registration			7/10/2024 5:33 PM
Details	Last Recertification Date	Insert	New Registration			7/10/2024 5:33 PM
Details	Grant Number	Insert	New Registration			7/10/2024 5:33 PM
Details	340B ID	Insert	New Registration			7/10/2024 5:33 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/10/2024 5:33 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/10/2024 5:33 PM
Details	Medicare Provider Number	Insert	New Registration		360218	7/10/2024 5:33 PM
Details	Entity Name	Insert	New Registration		LICKING MEMORIAL HOSPITAL	7/10/2024 5:33 PM
Details	NOFO Number	Insert	New Registration			7/10/2024 5:33 PM
Details	Program Code	Insert	New Registration		DSH	7/10/2024 5:33 PM
Details	Entity Subname	Insert	New Registration		LMH RHEUMATOLOGY CLINIC	7/10/2024 5:33 PM
Dates	Participating Approval Date	Insert	New Registration			7/10/2024 5:33 PM
Details	State	Insert	New Registration		Pending	7/10/2024 5:33 PM
Dates	Registration Date	Insert	New Registration		7/10/2024 5:33:59 PM	7/10/2024 5:33 PM
Dates	Signed By Date	Insert	New Registration			7/10/2024 5:33 PM
Dates	Start Date	Insert	New Registration			7/10/2024 5:33 PM
Terminations	Termination Comments	Insert	New Registration			7/10/2024 5:33 PM
Terminations	Termination Date	Insert	New Registration			7/10/2024 5:33 PM
Terminations	Termination Effective Date	Insert	New Registration			7/10/2024 5:33 PM
Terminations	Termination Reason	Insert	New Registration			7/10/2024 5:33 PM