Covered Entity Details

DSH360096A EAST LIVERPOOL CITY HOSPITAL (ToBeTerminated) - information as of 6/16/2025 12:58:27 AM

Main Details

Name

EAST LIVERPOOL CITY HOSPITAL

Subdivision Name

Wellsville Rural Health Clinic - Primary care, family medicine

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360096A

Medicare Provider Number

360096

Outpatient Facility Provider Number

Additional Details

Current Program Status

ToBeTerminated

Registration Date

7/11/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/1/2024

Last Recertification Date

Termination Date
Termination Reason

7/1/2025
DSH percentage below statutory minimum

Contacts

Authorizing Official

East Liverpool City Hospital
Jamie McKenzie, CFO
(330) 386-2655

Primary Contact

East Liverpool City Hospital
Bill Smith, Director of Pharmacy
(330) 386-2023

Addresses

Street Address

601 Main St
Wellsville, OH 43968-1662

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	2413481	1659375673
WV	0001564000	1659375673

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
DSH360096A	Child	DSH	EAST LIVERPOOL CITY HOSPITAL	Wellsville Rural Health Clinic - Primary care, family medicine	601 Main St	Wellsville	OH	ToBeTerminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/29/2025 12:00:00 AM	6/2/2025 6:33 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/2/2025 6:33 AM
Terminations	Termination Date	Update	Termination Request		7/1/2025 12:00:00 AM	6/2/2025 6:33 AM
Terminations	Termination Effective Date	Update	Termination Request		5/30/2025 12:00:00 AM	6/2/2025 6:33 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/2/2025 6:33 AM
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Addresses	Main Address	Insert	New Registration		601 Main St Wellsville, OH 43968-1662	8/1/2024 7:31 AM
Contacts	Signed By	Insert	New Registration		McKenzie, Jamie CFO East Liverpool City Hospital 3303862655	8/1/2024 7:31 AM
Details	340B ID	Update	New Registration		DSH360096A	8/1/2024 7:31 AM
Details	Entity Subname	Update	New Registration	Wellsville Rural Health Clinic	Wellsville Rural Health Clinic - Primary care, family medicine	8/1/2024 7:31 AM
Dates	Participating Approval Date	Update	New Registration		8/1/2024 7:31:37 AM	8/1/2024 7:31 AM
Details	State	Update	New Registration	Pending	Approved	8/1/2024 7:31 AM
Dates	Signed By Date	Update	New Registration		7/25/2024 11:39:22 AM	8/1/2024 7:31 AM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/1/2024 7:31 AM
Addresses	Main Address	Insert	New Registration		601 Main St Wellsville, OH 43968-1662	7/25/2024 11:39 AM
Addresses	Main Address	Insert	New Registration		601 Main St Wellsville, OH 43968-1662	7/11/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2413481	7/11/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	7/11/2024 12:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2024 12:13 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0001564000	7/11/2024 12:13 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	7/11/2024 12:13 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1659375673	7/11/2024 12:13 PM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/11/2024 12:13 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1659375673	7/11/2024 12:13 PM
Medicaid Billing	NPI: State	Insert	New Registration		WV	7/11/2024 12:13 PM
Contacts	Primary Contact	Insert	New Registration		Smith, Bill Director of Pharmacy East Liverpool City Hospital 3303862023	7/11/2024 12:13 PM
Contacts	Authorizing Official	Insert	New Registration		McKenzie, Jamie CFO East Liverpool City Hospital 3303862655	7/11/2024 12:13 PM
Details	Assistance Received From Date	Insert	New Registration			7/11/2024 12:13 PM
Details	Assistance Received To Date	Insert	New Registration			7/11/2024 12:13 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2024 12:13 PM
Details	Grant Number	Insert	New Registration			7/11/2024 12:13 PM
Details	340B ID	Insert	New Registration			7/11/2024 12:13 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2024 12:13 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2024 12:13 PM
Details	Medicare Provider Number	Insert	New Registration		360096	7/11/2024 12:13 PM
Details	Entity Name	Insert	New Registration		EAST LIVERPOOL CITY HOSPITAL	7/11/2024 12:13 PM
Details	NOFO Number	Insert	New Registration			7/11/2024 12:13 PM
Details	Program Code	Insert	New Registration		DSH	7/11/2024 12:13 PM
Details	Entity Subname	Insert	New Registration		Wellsville Rural Health Clinic	7/11/2024 12:13 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2024 12:13 PM
Details	State	Insert	New Registration		Pending	7/11/2024 12:13 PM
Dates	Registration Date	Insert	New Registration		7/11/2024 12:13:31 PM	7/11/2024 12:13 PM
Dates	Signed By Date	Insert	New Registration			7/11/2024 12:13 PM
Dates	Start Date	Insert	New Registration			7/11/2024 12:13 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2024 12:13 PM
Terminations	Termination Date	Insert	New Registration			7/11/2024 12:13 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2024 12:13 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2024 12:13 PM