Covered Entity Details

DSH510058Y CAMDEN-CLARK MEMORIAL HOSP (Active) - information as of 4/25/2025 5:37:10 PM

Main Details

Name

CAMDEN-CLARK MEMORIAL HOSP

Subdivision Name

Southgate Podiatry - Podiatry

Type

Disproportionate Share Hospital

Rural

340B ID

DSH510058Y

Medicare Provider Number

510058

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/11/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/28/2024

Last Recertification Date

Contacts

Authorizing Official

Camden Clark Medical Center DBA Camden-Clark Memorial Hospital
Kyle Anthony Pierson, CFO
(304) 424-2202

Primary Contact

WVU Medicine
Barbra Sue May, Enterprise Manager, 340B Program
(304) 290-9830

Addresses

Street Address

2107 Pike Street
Suite 6
Parkersburg, WV 26101

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
WV		1699704254,1760551576
PA		1699704254,1760551576
OH		1699704254,1760551576
VA		1699704254,1760551576
KY		1699704254,1760551576

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
DSH510058A	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Oncology Clinic	705 GARFIELD AVE	PARKERSBURG	WV	Active
DSH510058B	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Ambulatory Infusion Center	705 Garfield Avenue	Parkersburg	WV	Active
DSH510058C	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Cardiac Diagnostic Services - Cardiac Diagnostic Services	1013 Garfield Avenue	Parkersburg	WV	Active
DSH510058D	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Wound Management Center - Wound Management	801 Garfield Avenue	Parkersburg	WV	Active
DSH510058E	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	RHEUMATOLOGY - Rheumatology	602 Division Street	PARKERSBURG	WV	Active
DSH510058F	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	GASTROENTEROLOGY - GASTROENTEROLOGY	1905 Ann Street	PARKERSBURG	WV	Terminated
DSH510058G	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Gastro Cornerstone - Gastroenterology	705 Garfield Avenue	Parkersburg	WV	Active
DSH510058H	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Camden Clark Pulmonology - Camden Clark Pulmonologist	800 Garfield Avenue	Parkersburg	WV	Active
DSH510058J	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Patriot Point - Patriot Point	2838 Pike Street	Parkersburg	WV	Terminated
DSH510058K	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Family Medicine - Family Medicine - Residency	800 Garfield Avenue	Parkersburg	WV	Active
DSH510058L	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	General Surgery - General Surgery PMC III	418 Grand Park Drive	Parkersburg	WV	Active
DSH510058M	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Primary Care - Primary Care - Cornerstone	1907 Ann Street	Parkersburg	WV	Active
DSH510058N	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Primary Care - Primary Care	2107 Pike Street	Parkersburg	WV	Active
DSH510058P	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Primary Care - Primary Care PMC III	418 Grand Park Drive	Parkersburg	WV	Terminated
DSH510058Q	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Camden Clark Urology - Camden Clark Urology	604 Ann Street	Parkersburg	WV	Active
DSH510058R	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Primary Care - Harbor Point Primary Care	108 Osprey Drive	Williamstown	WV	Active
DSH510058S	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	ENDOCRINOLOGY - Endocrine Clinic	604 ANN ST	PARKERSBURG	WV	Terminated
DSH510058T	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Pain Management - Pain Management	800 Ann Street	Parkersburg	WV	Active
DSH510058U	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Diabetes and Endocrine - Diabetes and Endocrine	1901 Ann Street	Parkersburg	WV	Active
DSH510058V	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	clinic - Infectious Disease	800 Grand Central Mall	Vienna	WV	Active
DSH510058W	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	clinic - CCMC MOVMG Vienna - Family Medicine	800 Grand Central Mall	Vienna	WV	Active
DSH510058X	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	SOUTHGATE PRIMARY CARE - Primary Care	2107 PIKE ST	PARKERSBURG	WV	Terminated
DSH510058Y	Child	DSH	CAMDEN-CLARK MEMORIAL HOSP	Southgate Podiatry - Podiatry	2107 Pike Street	Parkersburg	WV	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		Pierson, Kyle Anthony CFO Camden Clark Medical Center DBA Camden-Clark Memorial Hospital 3044242202	10/28/2024 1:30 PM
Details	340B ID	Update	New Registration		DSH510058Y	10/28/2024 1:30 PM
Details	Entity Name	Update	New Registration	CAMDEN-CLARK MEMORIAL HOSPITAL	CAMDEN-CLARK MEMORIAL HOSP	10/28/2024 1:30 PM
Details	Entity Subname	Update	New Registration	Southgate Podiatry	Southgate Podiatry - Podiatry	10/28/2024 1:30 PM
Dates	Participating Approval Date	Update	New Registration		10/28/2024 1:30:04 PM	10/28/2024 1:30 PM
Details	State	Update	New Registration	Pending	Approved	10/28/2024 1:30 PM
Dates	Signed By Date	Update	New Registration		10/14/2024 8:14:21 AM	10/28/2024 1:30 PM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/28/2024 1:30 PM
Addresses	Main Address	Insert	New Registration		2107 Pike Street Suite 6 Parkersburg, WV 26101	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1699704254	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		WV	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760551576	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		WV	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1699704254	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760551576	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1699704254	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760551576	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1699704254	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		VA	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760551576	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		VA	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1699704254	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	10/11/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760551576	10/11/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	10/11/2024 9:33 AM
Contacts	Authorizing Official	Insert	New Registration		Pierson, Kyle Anthony CFO Camden Clark Medical Center DBA Camden-Clark Memorial Hospital 3044242202	10/11/2024 9:33 AM
Contacts	Primary Contact	Insert	New Registration		May, Barbra Sue Enterprise Manager, 340B Program WVU Medicine 3042909830	10/11/2024 9:33 AM
Details	Assistance Received From Date	Insert	New Registration			10/11/2024 9:33 AM
Details	Assistance Received To Date	Insert	New Registration			10/11/2024 9:33 AM
Details	Last Recertification Date	Insert	New Registration			10/11/2024 9:33 AM
Details	Grant Number	Insert	New Registration			10/11/2024 9:33 AM
Details	340B ID	Insert	New Registration			10/11/2024 9:33 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2024 9:33 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2024 9:33 AM
Details	Medicare Provider Number	Insert	New Registration		510058	10/11/2024 9:33 AM
Details	Entity Name	Insert	New Registration		CAMDEN-CLARK MEMORIAL HOSPITAL	10/11/2024 9:33 AM
Details	NOFO Number	Insert	New Registration			10/11/2024 9:33 AM
Details	Program Code	Insert	New Registration		DSH	10/11/2024 9:33 AM
Details	Entity Subname	Insert	New Registration		Southgate Podiatry	10/11/2024 9:33 AM
Dates	Participating Approval Date	Insert	New Registration			10/11/2024 9:33 AM
Details	State	Insert	New Registration		Pending	10/11/2024 9:33 AM
Dates	Registration Date	Insert	New Registration		10/11/2024 9:33:42 AM	10/11/2024 9:33 AM
Dates	Signed By Date	Insert	New Registration			10/11/2024 9:33 AM
Dates	Start Date	Insert	New Registration			10/11/2024 9:33 AM
Terminations	Termination Comments	Insert	New Registration			10/11/2024 9:33 AM
Terminations	Termination Date	Insert	New Registration			10/11/2024 9:33 AM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2024 9:33 AM
Terminations	Termination Reason	Insert	New Registration			10/11/2024 9:33 AM