Covered Entity Details

DSH360014F OBLENESS MEMORIAL HOSPITAL (Active) - information as of 5/1/2025 11:52:04 PM

Main Details

Name

OBLENESS MEMORIAL HOSPITAL

Subdivision Name

Wound Care Center - Wound Care Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360014F

Medicare Provider Number

360014

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/10/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/24/2024

Last Recertification Date

Contacts

Authorizing Official

OhioHealth
Lee Ann Lucas-Helber, President
(740) 589-3510

Primary Contact

OhioHealth
Heidi Elizabeth Haldiman, Pharmacy Compliance Coordinator
(614) 566-0398

Addresses

Street Address

444 West Union Street
Suite D
Athens, OH 45701

Billing Address

OhioHealth Corporation
PO Box 9
Columbus, OH 43216

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	8017265	1710913462

Shipping Addresses

Shipping Address 1

OhioHealth O'Bleness Memorial Hospital
55 Hospital Drive
Athens, OH 45701

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
DSH360014A	Child	DSH	OBLENESS MEMORIAL HOSPITAL	SHELTERING ARMS FOUNDATION INC / Obleness Infusion Center	75HOSPITAL DR	ATHENS	OH	Active
DSH360014B	Child	DSH	OBLENESS MEMORIAL HOSPITAL	Cardiac Catheterization - Cardiac Cath Lab	65 Hospital Drive	Athens	OH	Active
DSH360014C	Child	DSH	OBLENESS MEMORIAL HOSPITAL	Vascular Lab - Vascular Lab	65 Hospital Drive	Athens	OH	Active
DSH360014D	Child	DSH	OBLENESS MEMORIAL HOSPITAL	Respiratory Therapy - Pulmonary Services	65 Hospital Drive	Athens	OH	Active
DSH360014E	Child	DSH	OBLENESS MEMORIAL HOSPITAL	Procedural Care Unit - Procedural Care Unit	65 Hospital Dr	Athens	OH	Active
DSH360014F	Child	DSH	OBLENESS MEMORIAL HOSPITAL	Wound Care Center - Wound Care Center	444 West Union Street	Athens	OH	Active
DSH360014G	Child	DSH	OBLENESS MEMORIAL HOSPITAL	Pain Management Clinic - Pain Management Clinic	265 West Union Street	Athens	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Lucas-Helber, Lee Ann President OhioHealth 7405893510	10/24/2024 7:13 AM
Details	340B ID	Update	New Registration		DSH360014F	10/24/2024 7:13 AM
Details	Entity Subname	Update	New Registration	Wound Care Center	Wound Care Center - Wound Care Center	10/24/2024 7:13 AM
Dates	Participating Approval Date	Update	New Registration		10/24/2024 7:13:27 AM	10/24/2024 7:13 AM
Details	State	Update	New Registration	Pending	Approved	10/24/2024 7:13 AM
Dates	Signed By Date	Update	New Registration		10/14/2024 12:16:47 PM	10/24/2024 7:13 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/24/2024 7:13 AM
Addresses	Main Address	Insert	New Registration		444 West Union Street Suite D Athens, OH 45701	10/10/2024 10:00 AM
Addresses	Billing Address	Insert	New Registration		OhioHealth Corporation PO Box 9 Columbus, OH 43216	10/10/2024 10:00 AM
Addresses	Shipping Address	Insert	New Registration		OhioHealth O'Bleness Memorial Hospital 55 Hospital Drive Athens, OH 45701	10/10/2024 10:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/10/2024 10:00 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		8017265	10/10/2024 10:00 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/10/2024 10:00 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1710913462	10/10/2024 10:00 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/10/2024 10:00 AM
Contacts	Authorizing Official	Insert	New Registration		Lucas-Helber, Lee Ann President OhioHealth 7405893510	10/10/2024 10:00 AM
Contacts	Primary Contact	Insert	New Registration		Haldiman, Heidi Elizabeth Pharmacy Compliance Coordinator OhioHealth 6145660398	10/10/2024 10:00 AM
Details	Assistance Received From Date	Insert	New Registration			10/10/2024 10:00 AM
Details	Assistance Received To Date	Insert	New Registration			10/10/2024 10:00 AM
Details	Last Recertification Date	Insert	New Registration			10/10/2024 10:00 AM
Details	Grant Number	Insert	New Registration			10/10/2024 10:00 AM
Details	340B ID	Insert	New Registration			10/10/2024 10:00 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/10/2024 10:00 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/10/2024 10:00 AM
Details	Medicare Provider Number	Insert	New Registration		360014	10/10/2024 10:00 AM
Details	Entity Name	Insert	New Registration		OBLENESS MEMORIAL HOSPITAL	10/10/2024 10:00 AM
Details	NOFO Number	Insert	New Registration			10/10/2024 10:00 AM
Details	Program Code	Insert	New Registration		DSH	10/10/2024 10:00 AM
Details	Entity Subname	Insert	New Registration		Wound Care Center	10/10/2024 10:00 AM
Dates	Participating Approval Date	Insert	New Registration			10/10/2024 10:00 AM
Details	State	Insert	New Registration		Pending	10/10/2024 10:00 AM
Dates	Registration Date	Insert	New Registration		10/10/2024 10:00:29 AM	10/10/2024 10:00 AM
Dates	Signed By Date	Insert	New Registration			10/10/2024 10:00 AM
Dates	Start Date	Insert	New Registration			10/10/2024 10:00 AM
Terminations	Termination Comments	Insert	New Registration			10/10/2024 10:00 AM
Terminations	Termination Date	Insert	New Registration			10/10/2024 10:00 AM
Terminations	Termination Effective Date	Insert	New Registration			10/10/2024 10:00 AM
Terminations	Termination Reason	Insert	New Registration			10/10/2024 10:00 AM