Covered Entity Details

CAH141351-03 County of Clay DBA Clay County Hospital (Approved) - information as of 6/16/2025 12:57:12 AM

Main Details

Name

County of Clay DBA Clay County Hospital

Subdivision Name

COUNTY OF CLAY - Clay City Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141351-03

Medicare Provider Number

141351

Outpatient Facility Provider Number

148558

Additional Details

Current Program Status

Approved

Registration Date

4/8/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/9/2025

Last Recertification Date

Contacts

Authorizing Official

Clay County Hospital
Jason Harris, Director of Pharmacy
(618) 662-1653

Primary Contact

Clay County Hospital
Robert Raymond Sellers, President
(618) 662-1628

Addresses

Street Address

939 SUNSET RD SW
CLAY CITY, IL 62824-1113

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?
No

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
CAH141351-01	Child	CAH	County of Clay DBA Clay County Hospital	Clay County Hospital Medical Clinic	929 Stacy Burk Drive	Flora	IL	Active
CAH141351-02	Child	CAH	County of Clay DBA Clay County Hospital	Louisville Medical Clinic	935 Bryant	Louisville	IL	Active
CAH141351-03	Child	CAH	County of Clay DBA Clay County Hospital	COUNTY OF CLAY - Clay City Clinic	939 SUNSET RD SW	CLAY CITY	IL	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Harris, Jason Director of Pharmacy Clay County Hospital 6186621653	4/9/2025 6:50 AM
Details	340B ID	Update	New Registration		CAH141351-03	4/9/2025 6:50 AM
Details	Entity Name	Update	New Registration	CLAY COUNTY HOSPITAL	County of Clay DBA Clay County Hospital	4/9/2025 6:50 AM
Details	Entity Subname	Update	New Registration	COUNTY OF CLAY	COUNTY OF CLAY - Clay City Clinic	4/9/2025 6:50 AM
Dates	Participating Approval Date	Update	New Registration		4/9/2025 6:50:46 AM	4/9/2025 6:50 AM
Details	State	Update	New Registration	Pending	Approved	4/9/2025 6:50 AM
Dates	Signed By Date	Update	New Registration		4/8/2025 2:06:52 PM	4/9/2025 6:50 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/9/2025 6:50 AM
Addresses	Main Address	Insert	New Registration		939 SUNSET RD SW CLAY CITY, IL 62824-1113	4/8/2025 2:06 PM
Contacts	Authorizing Official	Insert	New Registration		Harris, Jason Director of Pharmacy Clay County Hospital 6186621653	4/8/2025 2:06 PM
Contacts	Primary Contact	Insert	New Registration		Sellers, Robert Raymond President Clay County Hospital 6186621628	4/8/2025 2:06 PM
Details	Assistance Received From Date	Insert	New Registration			4/8/2025 2:06 PM
Details	Assistance Received To Date	Insert	New Registration			4/8/2025 2:06 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2025 2:06 PM
Details	Grant Number	Insert	New Registration			4/8/2025 2:06 PM
Details	340B ID	Insert	New Registration			4/8/2025 2:06 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2025 2:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2025 2:06 PM
Details	Medicare Provider Number	Insert	New Registration		141351	4/8/2025 2:06 PM
Details	Entity Name	Insert	New Registration		CLAY COUNTY HOSPITAL	4/8/2025 2:06 PM
Details	NOFO Number	Insert	New Registration			4/8/2025 2:06 PM
Details	Program Code	Insert	New Registration		CAH	4/8/2025 2:06 PM
Details	Entity Subname	Insert	New Registration		COUNTY OF CLAY	4/8/2025 2:06 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2025 2:06 PM
Details	State	Insert	New Registration		Pending	4/8/2025 2:06 PM
Dates	Registration Date	Insert	New Registration		4/8/2025 2:06:52 PM	4/8/2025 2:06 PM
Dates	Signed By Date	Insert	New Registration			4/8/2025 2:06 PM
Dates	Start Date	Insert	New Registration			4/8/2025 2:06 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2025 2:06 PM
Terminations	Termination Date	Insert	New Registration			4/8/2025 2:06 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2025 2:06 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2025 2:06 PM