Covered Entity Details

DSH180012 Baptist Health Hardin (Active) - information as of 5/19/2025 12:44:23 AM

Main Details

Name

Baptist Health Hardin

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH180012

Medicare Provider Number

180012

Additional Details

Current Program Status

Active

Registration Date

5/30/2010

Participating Start Date

4/1/2017

Participating Approval Date

5/30/2010

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Baptist Health Hardin
Thomas Carrico, Chief Operating Officer
(270) 706-5321

Primary Contact

Baptist Health Hardin
Christopher Michael Diem, System 340B Director
(270) 979-3725

Addresses

Street Address

913 NORTH DIXIE AVENUE
ELIZABETHTOWN, KY 42701

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Previously participated as a DSH from 7/1/2010-7/1/2011. Reinstated as a DSH 4/1/2017. 6/15/2010- SUBMITTED DOC. TO SUPPORT ELIG. DSH PERCENTAGE.	03/15/2017
6/15/2010- SUBMITTED DOC. TO SUPPORT ELIG. DSH PERCENTAGE.	07/01/2011

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
KY		1720696149,1689282147,1215545777,1013525583,1497585624
IN		1013525583,1215545777,1689282147
TN		1013525583,1215545777,1689282147

Shipping Addresses

Shipping Address 1

Baptist Health Community Pharmacy
913 North Dixie Avenue
Elizabethtown, KY 42701

Shipping Address 2

Baptist Health Consolidated Pharmacy Services
1051 New Moody Lane
STE 1500
La Grange, KY 40031

Shipping Address 3

Baptist Health Hardin Pavilion Community Pharmacy
200 Cardinal Dr
STE 205C
Elizabethtown, KY 42701

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/15/2018	04/01/2018	02/16/2022	03/07/2022
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/15/2018	04/01/2018	02/16/2022	03/07/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/15/2018	04/01/2018	01/03/2023	01/03/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	02/10/2023	04/01/2023	07/01/2024	07/10/2024
Contract Detail	APOTHECARE PHARMACY II AT CARDINAL	1028 N DIXIE AVE	STE 100	ELIZABETHTOWN	KY	42701-2522	10/03/2017	01/01/2018	03/23/2019	04/07/2019
Contract Detail	APOTHECARE PHARMACY OF	ELIZABETHTOWN	1239 WOODLAND DR STE 102	ELIZABETHTOWN	KY	42701-2770	10/03/2017	01/01/2018	03/23/2019	04/07/2019
Contract Detail	APOTHECARE PHARMACY OF ELIZABETHTOWN	DBA APOTHECARE PHARMACY III	189 E LINCOLN TRAIL BLVD	RADCLIFF	KY	40160-1253	10/03/2017	01/01/2018	03/23/2019	04/07/2019
Contract Detail	APOTHECARE PHARMACY VINE GROVE	107 CRUTCHER ST		VINE GROVE	KY	40175	10/03/2017	01/01/2018	03/23/2019	04/07/2019
Contract Detail	BAPTIST HEALTH CORBIN	1 Trillium Way		Corbin	KY	40701	07/13/2020	10/01/2020	04/03/2023	04/03/2023
Contract Detail	BAPTIST HEALTH LEXINGTON RETAIL PHARMACY	1700 NICHOLASVILLE RD STE N1210		LEXINGTON	KY	40503-1463	04/15/2022	07/01/2022		11/25/2024
Contract Detail	BAPTIST HEALTH SHARED SERVICES PHARMACY	1051 NEW MOODY LN STE 1400		LA GRANGE	KY	40031	04/08/2024	07/01/2024		11/25/2024
Contract Detail	BARDSTOWN PHARMACY SERVICE, LLC	D.B.A. CRUME DRUG STORE	111 W FLAGET ST	BARDSTOWN	KY	40004-1422	10/03/2017	01/01/2018	12/18/2017	12/18/2017
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/06/2023	04/10/2023		11/25/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/06/2023	04/10/2023		11/25/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	07/01/2024	10/01/2024		11/25/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	07/01/2024	10/01/2024		11/25/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/06/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	1471 E BUSINESS CENTER DRIVE SUITE 500	MOUNT PROSPECT	IL	60056	04/06/2023	07/01/2023	01/24/2025	04/14/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/06/2023	04/10/2023		11/25/2024
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/05/2023	04/10/2023		11/25/2024
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/06/2023	04/10/2023		11/25/2024
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	04/07/2019	07/01/2019	08/01/2021	08/01/2021
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	04/06/2023	04/10/2023		11/25/2024
Contract Detail	JEFF'S PRESCRIPTION SHOP	2415 RING ROAD		ELIZABETHTOWN	KY	42701	10/03/2017	01/01/2018	07/01/2018	09/10/2018
Contract Detail	KENTUCKY CVS PHARMACY, L.L.C.	CVS/PHARMACY #10048	1571 N DIXIE AVENUE	ELIZABETHTOWN	KY	42701	10/16/2017	01/01/2018	07/01/2018	09/10/2018
Contract Detail	KENTUCKY CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06338	101 EAST BROADWAY	CAMPBELLSVILLE	KY	42718	04/05/2023	04/10/2023		11/25/2024
Contract Detail	KENTUCKY CVS PHARMACY, L.L.C.	CVS/PHARMACY #10048	1571 N DIXIE AVENUE	ELIZABETHTOWN	KY	42701	04/05/2023	04/10/2023		11/25/2024
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	11403 BLUEGRASS PARKWAY SUITE 400	LOUISVILLE	KY	40299-2398	10/26/2019	01/01/2020	09/12/2020	09/12/2020
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/13/2023	10/01/2023		11/25/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/13/2023	10/01/2023		11/25/2024
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/13/2023	10/01/2023		11/25/2024
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/05/2023	04/10/2023		11/25/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	04/05/2023	04/10/2023		11/25/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/05/2023	04/10/2023		11/25/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/05/2023	04/10/2023		11/25/2024
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/06/2023	04/10/2023		11/25/2024
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/06/2023	04/10/2023		11/25/2024
Contract Detail	SCOTT-WILSON, INC.	DBA BIOSCRIP INFUSION SERVICES	2380 FORTUNE DRIVE SUITE 130	LEXINGTON	KY	40509	04/07/2019	07/01/2019	09/12/2020	09/12/2020
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	01/17/2023	04/01/2023		11/25/2024
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	01/17/2023	04/01/2023		11/25/2024
Contract Detail	UK - SPECIALTY PHARMACY	UNIVERSITY OF KENTUCKY HOSPITAL	800 ROSE ST RM HC 201 RM HC201	LEXINGTON	KY	40536-7001	10/04/2017	01/01/2018	03/26/2020	07/15/2020
Contract Detail	WAL-MART PHARMACY 10-0709	100 WAL-MART DRIVE		ELIZABETHTOWN	KY	42701	10/16/2017	01/01/2018	11/15/2019	11/15/2019
Contract Detail	WAL-MART PHARMACY 10-1165	1165 WAL-MART WAY		RADCLIFF	KY	40160	04/07/2019	07/01/2019	11/15/2019	11/15/2019
Contract Detail	WALGREEN CO	DBA: WALGREENS #11761	635 S DIXIE BLVD	RADCLIFF	KY	40160	06/02/2023	06/05/2023	07/01/2024	07/18/2024
Contract Detail	WALGREEN CO	DBA: WALGREENS #11307	824 N 3RD STREET	BARDSTOWN	KY	40004	06/02/2023	06/05/2023		11/25/2024
Contract Detail	WALGREEN CO	DBA: WALGREENS #11761	635 S DIXIE BLVD	RADCLIFF	KY	40160	10/15/2024	10/16/2024		11/25/2024
Contract Detail	WALGREEN CO.	WALGREENS #17478	415 N LINCOLN BLVD	HODGENVILLE	KY	42748	06/02/2023	06/05/2023	07/01/2024	07/18/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02225	1008 N MULBERRY ST	ELIZABETHTOWN	KY	42701-2037	06/02/2023	06/05/2023	07/01/2024	07/18/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04123	1602 N. DIXIE AVE	ELIZABETHTOWN	KY	42701	06/02/2023	06/05/2023	07/01/2024	07/18/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09524	10201 DIXIE HWY	LOUISVILLE	KY	40272	06/02/2023	06/05/2023		11/25/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12775	550 W DIXIE AVE	ELIZABETHTOWN	KY	42701	06/02/2023	06/05/2023	07/01/2024	07/18/2024
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16372	532 S 4TH ST UNIT 532	LOUISVILLE	KY	40202	06/02/2023	06/05/2023	07/01/2024	07/18/2024
Contract Detail	WALGREEN CO.	WALGREENS #17304	610 BYPASS RD	BRANDENBURG	KY	40108	06/02/2023	06/05/2023	07/01/2024	07/18/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10207	152 N BUCKMAN ST	SHEPHERDSVILLE	KY	40165-4900	06/02/2023	06/05/2023		11/25/2024
Contract Detail	WALGREEN CO.	WALGREENS #17478	415 N LINCOLN BLVD	HODGENVILLE	KY	42748	10/15/2024	10/16/2024		11/25/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12775	550 W DIXIE AVE	ELIZABETHTOWN	KY	42701	10/15/2024	10/16/2024		11/25/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04123	1602 N. DIXIE AVE	ELIZABETHTOWN	KY	42701	10/15/2024	10/16/2024		11/25/2024
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16372	532 S 4TH ST UNIT 532	LOUISVILLE	KY	40202	10/15/2024	10/16/2024		11/25/2024
Contract Detail	WALGREEN CO.	WALGREENS #17304	610 BYPASS RD	BRANDENBURG	KY	40108	10/15/2024	10/16/2024		11/25/2024
Contract Detail	Walgreens Central Fill #21399	4132Plainfield Rd	Ste 110	Indianapolis	IN	46231-7021	06/02/2023	06/05/2023	07/01/2024	07/18/2024
Contract Detail	Walgreens Central Fill #21399	4132Plainfield Rd	Ste 110	Indianapolis	IN	46231-7021	10/15/2024	10/16/2024		11/25/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH180012A	Child	DSH	HARDIN MEMORIAL HOSPITAL	HELMWOOD RADIOLOGY	914 NORTH DIXIE AVENUE 307	ELIZABETHTOWN	KY	Terminated
DSH180012B	Child	DSH	HARDIN MEMORIAL HOSPITAL	HEARTLAND DIAGNOSTIC CENTER	1700 RING ROAD	ELIZABETHTOWN	KY	Terminated
DSH180012C	Child	DSH	HARDIN MEMORIAL HOSPITAL	NORTH HARDIN DIAGNOSTIC CENTER	1360 ROGERSVILLE ROAD	RADCLIFF	KY	Terminated
DSH180012D	Child	DSH	HARDIN MEMORIAL HOSPITAL	BARDSTOWN DIAGNOSTIC CENTER	201 S. 5TH STREET	BARDSTOWN	KY	Terminated
DSH180012F	Child	DSH	Baptist Health Hardin	Baptist Health Hardin Cancer Care Center	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012G	Child	DSH	HARDIN MEMORIAL HOSPITAL	ELIZABETHTOWN DIAGNOSTIC IMAGING	2409 RING ROAD,	ELIZABETHTOWN	KY	Terminated
DSH180012H	Child	DSH	Baptist Health Hardin	HMH-SURGICAL CENTER OF ELIZABETHTOWN	108 FINANCIAL PL	ELIZABETHTOWN	KY	Terminated
DSH180012J	Child	DSH	Baptist Health Hardin	Medical Oncology Clinic - Medical Oncology Physician Clinic	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012K	Child	DSH	HARDIN MEMORIAL HOSPITAL	Wound Care Clinic - Wound and Vascular physician clinic	1010 Woodland Drive	Elizabethtown	KY	Terminated
DSH180012L	Child	DSH	Baptist Health Hardin	HMH DIAB MGMT/HMH DISEASE MGMT - Diabetes	521 Robinbrooke Blvd	Elizabethtown	KY	Active
DSH180012M	Child	DSH	Baptist Health Hardin	Operating Rooms - Outpatient Surgery	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012N	Child	DSH	Baptist Health Hardin	Clinic - Complex Care	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012P	Child	DSH	Baptist Health Hardin	Operating Rooms - Preadmission Testing	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012Q	Child	DSH	Baptist Health Hardin	RADIOLOGY-DIAGNOSTIC - Radiology Diagnostic	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012R	Child	DSH	Baptist Health Hardin	LABORATORY - Laboratory	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012S	Child	DSH	Baptist Health Hardin	CARDIAC CATHETERIZATION - Cardiac Cath Lab	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012T	Child	DSH	Baptist Health Hardin	RESPIRATORY THERAPY - Respiratory Therapy	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012U	Child	DSH	Baptist Health Hardin	RADIOLOGY - THERAPEUTIC - Radiation Oncology Clinic	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012V	Child	DSH	Baptist Health Hardin	ELECTROCARDIOLOGY - Cardiology	200 Cardinal Drive	Elizabethtown	KY	Active
DSH180012W	Child	DSH	Baptist Health Hardin	RADIOLOGY - THERAPEUTIC - Radition Therapy	200 Cardinal Drive	Elizabethtown	KY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Dates	Last Date That 340B Drugs Purchased	Update	OPA Cancel Termination Request	1/1/2025 12:00:00 AM		11/25/2024 1:51 PM
Details	State	Update	OPA Cancel Termination Request	To Be Terminated	Active	11/25/2024 1:51 PM
Terminations	Termination Date	Update	OPA Cancel Termination Request	1/1/2025 12:00:00 AM		11/25/2024 1:51 PM
Terminations	Termination Effective Date	Update	OPA Cancel Termination Request	1/1/2025 12:00:00 AM		11/25/2024 1:51 PM
Terminations	Termination Reason	Update	OPA Cancel Termination Request	Change of covered entity type		11/25/2024 1:51 PM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	11/13/2024 3:29 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	11/13/2024 3:29 PM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	11/13/2024 3:29 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	11/13/2024 3:29 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	11/13/2024 3:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1497585624	10/15/2024 3:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	10/15/2024 3:12 PM
Addresses	Shipping Address	Insert	Change Request		Baptist Health Hardin Pavilion Community Pharmacy 200 Cardinal Dr STE 205C Elizabethtown, KY 42701	9/3/2024 1:27 PM
Details	Last Recertification Date	Update	Recertification	8/18/2023 2:10:30 PM	8/16/2024 9:30:30 AM	8/16/2024 9:30 AM
Addresses	Shipping Address	Update	Change Request	Baptist Health Consolidated Services Pharmacy 1051 New Moody Lane STE 1500 La Grange, KY 40031	Baptist Health Consolidated Pharmacy Services 1051 New Moody Lane STE 1500 La Grange, KY 40031	4/23/2024 1:35 PM
Addresses	Shipping Address	Insert	Change Request		Baptist Health Consolidated Services Pharmacy 1051 New Moody Lane STE 1500 La Grange, KY 40031	3/27/2024 8:29 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7100716050 (KY)		10/9/2023 8:34 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300056417 (IN)		10/9/2023 8:34 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	Q077818 (TN)		10/9/2023 8:34 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	01009844 (KY)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1619931466 (KY)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1750346359 (KY)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1639134141 (KY)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1447793492 (KY)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1447793492 (IN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1619931466 (IN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1639134141 (IN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1720696149 (IN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1750346359 (IN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1447793492 (TN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1619931466 (TN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1639134141 (TN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1720696149 (TN)		10/9/2023 8:34 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1750346359 (TN)		10/9/2023 8:34 AM
Details	Last Recertification Date	Update	Recertification	9/9/2022 10:22:39 AM	8/18/2023 2:10:30 PM	8/18/2023 2:10 PM
Contacts	Primary Contact	Update	Profile Change Request	Diem, Christopher Michael Pharmacy Program Manager Baptist Health Hardin 2709793725	Diem, Christopher Michael System 340B Director Baptist Health Hardin 2709793725	5/4/2023 3:43 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/18/2023 8:40 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300056417	4/18/2023 8:40 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/18/2023 8:40 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		Q077818	4/18/2023 8:40 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1013525583	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1215545777	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1447793492	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1619931466	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1639134141	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1689282147	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1720696149	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1750346359	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1013525583	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1215545777	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1447793492	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1619931466	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1639134141	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1689282147	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1720696149	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1750346359	4/18/2023 8:40 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/18/2023 8:40 AM
Details	Last Recertification Date	Update	Recertification	8/23/2021 9:09:27 AM	9/9/2022 10:22:39 AM	9/9/2022 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/6/2022 12:36 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100716050	7/6/2022 12:36 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	7/6/2022 12:36 PM
Contacts	Authorizing Official	Update	Change Request	Carrico, Thomas Chief Operating Officer Hardin Memorial Hospital 2707065321	Carrico, Thomas Chief Operating Officer Baptist Health Hardin 2707065321	3/8/2022 7:08 AM
Contacts	Authorizing Official	Update	Profile Change Request	Carrico, Thomas VP Operations Hardin Memorial Hospital 2707065321	Carrico, Thomas Chief Operating Officer Hardin Memorial Hospital 2707065321	3/7/2022 4:58 PM
Contacts	Primary Contact	Update	Change Request	Diem, Christopher Director, Retail Pharmacy Operations Hardin Memorial Health 2709793725	Diem, Christopher Michael Pharmacy Program Manager Baptist Health Hardin 2709793725	2/7/2022 11:26 AM
Contacts	Authorizing Official	Update	Profile Change Request	Carrico, Thomas VP Operations Hardin Memorial Hospital 2707065278	Carrico, Thomas VP Operations Hardin Memorial Hospital 2707065321	8/23/2021 9:19 AM
Details	Last Recertification Date	Update	Recertification	9/4/2020 7:02:34 AM	8/23/2021 9:09:27 AM	8/23/2021 9:09 AM
Addresses	Shipping Address	Delete	Change Request	Baptist Health Community Pharmacy 1st floor front entrance 913 North Dixie Avenue Elizabethtown, KY 42701		12/21/2020 7:15 AM
Addresses	Shipping Address	Insert	Change Request		Baptist Health Community Pharmacy 913 North Dixie Avenue Elizabethtown, KY 42701	12/21/2020 7:15 AM
Addresses	Shipping Address	Delete	Change Request	HMH Community Pharmacy 1st floor front entrance 913 North Dixie Ave Elizabethtown, KY 42701		12/10/2020 8:59 AM
Addresses	Shipping Address	Insert	Change Request		Baptist Health Community Pharmacy 1st floor front entrance 913 North Dixie Avenue Elizabethtown, KY 42701	12/10/2020 8:59 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	01009644 (KY)		9/4/2020 7:02 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/4/2020 7:02 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/4/2020 7:02 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/4/2020 7:02 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/4/2020 7:02 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/4/2020 7:02 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/4/2020 7:02 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/4/2020 7:02 AM
Medicaid Billing	NPI: State	Update	Recertification		KY	9/4/2020 7:02 AM
Details	Last Recertification Date	Update	Recertification	8/28/2019 9:25:53 AM	9/4/2020 7:02:34 AM	9/4/2020 7:02 AM
Details	Entity Name	Update	Recertification	HARDIN MEMORIAL HOSPITAL	Baptist Health Hardin	9/4/2020 7:02 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1720696149	7/30/2020 6:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1689282147	7/30/2020 6:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1215545777	7/30/2020 6:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013525583	7/30/2020 6:10 PM
Details	Last Recertification Date	Update	Recertification	8/17/2018 9:02:37 AM	8/28/2019 9:25:53 AM	8/28/2019 9:25 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1619931466	7/25/2019 8:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1750346359	7/25/2019 8:11 AM
Contacts	Primary Contact	Update	Change Request	Sullivan, Kevin Michael Director of Pharmacy Hardin Memorial Hospital 2707061108	Diem, Christopher Director, Retail Pharmacy Operations Hardin Memorial Health 2709793725	8/17/2018 9:07 AM
Details	Last Recertification Date	Update	Recertification	11/6/2017 3:13:28 PM	8/17/2018 9:02:37 AM	8/17/2018 9:02 AM
Details	Last Recertification Date	Update	Recertification	10/24/2017 2:41:54 PM	11/6/2017 3:13:28 PM	11/6/2017 3:13 PM
Details	Last Recertification Date	Update	Recertification		10/24/2017 2:41:54 PM	10/24/2017 2:41 PM
Addresses	Shipping Address	Insert	Change Request		HMH Community Pharmacy 1st floor front entrance 913 North Dixie Ave Elizabethtown, KY 42701	10/11/2017 8:58 AM
Contacts	Primary Contact	Update	Change Request	JETT, SUSAN REIMBURSEMENT MANAGER 2707061663	Sullivan, Kevin Michael Director of Pharmacy Hardin Memorial Hospital 2707061108	9/29/2017 8:28 AM
Contacts	Authorizing Official	Update	Change Request	GRAY, DAVID L. PRESIDENT 2707061006	Carrico, Thomas VP Operations Hardin Memorial Hospital 2707065278	9/29/2017 8:28 AM
Addresses	Main Address	Insert			913 NORTH DIXIE AVENUE ELIZABETHTOWN, KY 42701	7/13/2017 3:29 PM
Medicaid Billing	NPI: Number	Insert			1447793492	7/13/2017 3:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	3/15/2017 12:59 PM
Medicaid Billing	Medicaid: Number	Insert			01009844	3/15/2017 12:59 PM
Medicaid Billing	Medicaid: State	Insert			KY	3/15/2017 12:59 PM
Medicaid Billing	NPI: Number	Insert			1639134141	3/15/2017 12:59 PM
Details	State	Update		Terminated	Active	3/15/2017 12:59 PM
Dates	Start Date	Update		7/1/2010 12:00:00 AM	4/1/2017 12:00:00 AM	3/15/2017 12:59 PM
Terminations	Termination Date	Update		7/1/2011 12:00:00 AM		3/15/2017 12:59 PM
Terminations	Termination Reason	Update		DSH percentage below statutory minimum		3/15/2017 12:59 PM
Details	Comments Public	Insert			Previously participated as a DSH from 7/1/2010-7/1/2011. Reinstated as a DSH 4/1/2017. 6/15/2010- SUBMITTED DOC. TO SUPPORT ELIG. DSH PERCENTAGE.	3/15/2017 12:59 PM
Contacts	Primary Contact	Insert			JETT, SUSAN REIMBURSEMENT MANAGER 2707061663	8/31/2016 2:35 PM
Contacts	Authorizing Official	Insert			GRAY, DAVID L. PRESIDENT 2707061006	7/3/2014 4:20 PM
Details	Last Recertification Date	Insert				7/1/2011 11:24 AM
Details	Grant Number	Insert				7/1/2011 11:24 AM
Details	340B ID	Insert			DSH180012	7/1/2011 11:24 AM
Details	Is Authorizing Official EHB Data	Insert				7/1/2011 11:24 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/1/2011 11:24 AM
Details	Medicare Provider Number	Insert			180012	7/1/2011 11:24 AM
Details	Entity Name	Insert			HARDIN MEMORIAL HOSPITAL	7/1/2011 11:24 AM
Details	Program Code	Insert			DSH	7/1/2011 11:24 AM
Details	Entity Subname	Insert				7/1/2011 11:24 AM
Dates	Participating Approval Date	Insert			5/30/2010 12:00:00 AM	7/1/2011 11:24 AM
Details	State	Insert			Terminated	7/1/2011 11:24 AM
Dates	Registration Date	Insert			5/30/2010 12:00:00 AM	7/1/2011 11:24 AM
Dates	Signed By Date	Insert			1/27/2010 12:00:00 AM	7/1/2011 11:24 AM
Dates	Start Date	Insert			7/1/2010 12:00:00 AM	7/1/2011 11:24 AM
Terminations	Termination Comments	Insert				7/1/2011 11:24 AM
Terminations	Termination Date	Insert			7/1/2011 12:00:00 AM	7/1/2011 11:24 AM
Terminations	Termination Effective Date	Insert				7/1/2011 11:24 AM
Terminations	Termination Reason	Insert			DSH percentage below statutory minimum	7/1/2011 11:24 AM
Details	Comments Public	Insert			6/15/2010- SUBMITTED DOC. TO SUPPORT ELIG. DSH PERCENTAGE.	7/1/2011 11:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	5/30/2010 11:26 AM
Medicaid Billing	Medicaid: Number	Insert			01009644	5/30/2010 11:26 AM
Medicaid Billing	Medicaid: State	Insert			KY	5/30/2010 11:26 AM