Covered Entity Details

DSH010164B COOSA VALLEY MEDICAL CENTER (Active) - information as of 5/17/2025 10:49:34 PM

Main Details

Name

COOSA VALLEY MEDICAL CENTER

Subdivision Name

SYLACAUGA HEALTH CARE AUTHORITY - Davis Famiy Medicine

Type

Disproportionate Share Hospital

Rural

340B ID

DSH010164B

Medicare Provider Number

010164

Outpatient Facility Provider Number

018506

Additional Details

Current Program Status

Active

Registration Date

1/9/2025

Participating Start Date

4/1/2025

Participating Approval Date

1/17/2025

Last Recertification Date

Contacts

Authorizing Official

Coosa Valley Medical Center
Brad McCormick, CFO
(256) 401-4534

Primary Contact

Coosa Valley Medical Center
Roger Morris, Director of Pharmacy
(256) 401-4066

Addresses

Street Address

209 W Spring St
Suite 102
Sylacauga, AL 35150

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
AL		1861178733

Shipping Addresses

Shipping Address 1

The Sylacauga Health Care Authority
315 W Hickory St
Sylacauga, AL 35150

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
DSH010164A	Child	DSH	COOSA VALLEY MEDICAL CENTER	Hematology/Oncology - Coosa Valley Hematology and Oncology	209 W. Spring Street	Sylacauga	AL	Active
DSH010164B	Child	DSH	COOSA VALLEY MEDICAL CENTER	SYLACAUGA HEALTH CARE AUTHORITY - Davis Famiy Medicine	209 W Spring St	Sylacauga	AL	Active
DSH010164C	Child	DSH	COOSA VALLEY MEDICAL CENTER	SYLACAUGA HEALTH CARE AUTH - Nix Family Medicine	33733 US HIGHWAY 280	CHILDERSBURG	AL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		McCormick, Brad CFO Coosa Valley Medical Center 2564014534	1/17/2025 10:46 AM
Details	340B ID	Update	New Registration		DSH010164B	1/17/2025 10:46 AM
Details	Entity Subname	Update	New Registration	SYLACAUGA HEALTH CARE AUTHORITY	SYLACAUGA HEALTH CARE AUTHORITY - Davis Famiy Medicine	1/17/2025 10:46 AM
Dates	Participating Approval Date	Update	New Registration		1/17/2025 10:46:30 AM	1/17/2025 10:46 AM
Details	State	Update	New Registration	Pending	Approved	1/17/2025 10:46 AM
Dates	Signed By Date	Update	New Registration		1/9/2025 5:21:34 PM	1/17/2025 10:46 AM
Dates	Start Date	Update	New Registration		4/1/2025 12:00:00 AM	1/17/2025 10:46 AM
Contacts	Authorizing Official	Update	Profile Change Request	McCormick, Brad CFO Coosa Valley Medical Center 2564014535	McCormick, Brad CFO Coosa Valley Medical Center 2564014534	1/13/2025 5:42 PM
Addresses	Main Address	Insert	New Registration		209 W Spring St Suite 102 Sylacauga, AL 35150	1/9/2025 5:03 PM
Addresses	Shipping Address	Insert	New Registration		The Sylacauga Health Care Authority 315 W Hickory St Sylacauga, AL 35150	1/9/2025 5:03 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1861178733	1/9/2025 5:03 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	1/9/2025 5:03 PM
Contacts	Primary Contact	Insert	New Registration		Morris, Roger Director of Pharmacy Coosa Valley Medical Center 2564014066	1/9/2025 5:03 PM
Contacts	Authorizing Official	Insert	New Registration		McCormick, Brad CFO Coosa Valley Medical Center 2564014535	1/9/2025 5:03 PM
Details	Assistance Received From Date	Insert	New Registration			1/9/2025 5:03 PM
Details	Assistance Received To Date	Insert	New Registration			1/9/2025 5:03 PM
Details	Last Recertification Date	Insert	New Registration			1/9/2025 5:03 PM
Details	Grant Number	Insert	New Registration			1/9/2025 5:03 PM
Details	340B ID	Insert	New Registration			1/9/2025 5:03 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/9/2025 5:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/9/2025 5:03 PM
Details	Medicare Provider Number	Insert	New Registration		010164	1/9/2025 5:03 PM
Details	Entity Name	Insert	New Registration		COOSA VALLEY MEDICAL CENTER	1/9/2025 5:03 PM
Details	NOFO Number	Insert	New Registration			1/9/2025 5:03 PM
Details	Program Code	Insert	New Registration		DSH	1/9/2025 5:03 PM
Details	Entity Subname	Insert	New Registration		SYLACAUGA HEALTH CARE AUTHORITY	1/9/2025 5:03 PM
Dates	Participating Approval Date	Insert	New Registration			1/9/2025 5:03 PM
Details	State	Insert	New Registration		Pending	1/9/2025 5:03 PM
Dates	Registration Date	Insert	New Registration		1/9/2025 5:03:37 PM	1/9/2025 5:03 PM
Dates	Signed By Date	Insert	New Registration			1/9/2025 5:03 PM
Dates	Start Date	Insert	New Registration			1/9/2025 5:03 PM
Terminations	Termination Comments	Insert	New Registration			1/9/2025 5:03 PM
Terminations	Termination Date	Insert	New Registration			1/9/2025 5:03 PM
Terminations	Termination Effective Date	Insert	New Registration			1/9/2025 5:03 PM
Terminations	Termination Reason	Insert	New Registration			1/9/2025 5:03 PM