Covered Entity Details

CAH181310-01 CARROLL COUNTY MEMORIAL HOSPITAL (Active) - information as of 5/8/2025 10:22:14 PM

Main Details

Name

CARROLL COUNTY MEMORIAL HOSPITAL

Subdivision Name

CARROLL COUNTY RURAL HEALTH CLINIC

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH181310-01

Medicare Provider Number

181310

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

9/15/2011

Participating Start Date

10/1/2011

Participating Approval Date

9/27/2011

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Carroll Co Hospital
Kimberly Haverly, CEO
(502) 732-3275

Primary Contact

Carroll County Memorial Hospital
Herbert Alfred Hunter, Director of Pharmacy
(502) 732-3207

Addresses

Street Address

309 11TH STREET
CARROLLTON, KY 41008

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
Contract Detail	AVELLA OF COLUMBUS	4830 KNIGHTSBRIDGE BLVD STE C		COLUMBUS	OH	43214-2300	10/12/2018	01/01/2019			01/01/2019
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	10/12/2018	01/01/2019			01/01/2019

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH181310-01	Child	CAH	CARROLL COUNTY MEMORIAL HOSPITAL	CARROLL COUNTY RURAL HEALTH CLINIC	309 11TH STREET	CARROLLTON	KY	Active
CAH181310-02	Child	CAH	CARROLL COUNTY MEMORIAL HOSPITAL	Warsaw Family Practice	302 West Main St.	Warsaw	KY	Active
CAH181310-03	Child	CAH	CARROLL COUNTY MEMORIAL HOSPITAL	Carroll County Family Practice/Rural Health Clinic	309 11th St	Carrollton	KY	Terminated
CAH181310-04	Child	CAH	CARROLL COUNTY MEMORIAL HOSPITAL	Bedford Family Practice	470 Highway 421 N	Bedford	KY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/18/2023 8:56:47 AM	8/12/2024 1:01:09 PM	8/12/2024 1:01 PM
Details	Last Recertification Date	Update	Recertification	8/26/2022 1:22:45 PM	8/18/2023 8:56:47 AM	8/18/2023 8:56 AM
Details	Last Recertification Date	Update	Recertification	9/3/2021 10:07:43 AM	8/26/2022 1:22:45 PM	8/26/2022 1:22 PM
Details	Last Recertification Date	Update	Recertification	8/20/2020 9:03:29 AM	9/3/2021 10:07:43 AM	9/3/2021 10:07 AM
Contacts	Primary Contact	Update	Change Request	Abplanalp, Larry L Director Pharmacy Carroll Co. Hospital 8125992859	Hunter, Herbert Alfred Director of Pharmacy Carroll County Memorial Hospital 5027323207	4/1/2021 2:52 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 2:22:33 PM	8/20/2020 9:03:29 AM	8/20/2020 9:03 AM
Contacts	Authorizing Official	Update	AO Change Request	Dees, Kim CEO Carroll Co Hospital 5027327411	Haverly, Kimberly CEO Carroll Co Hospital 5027323275	6/29/2020 11:07 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 9:42:38 AM	8/20/2019 2:22:33 PM	8/20/2019 2:22 PM
Contacts	Authorizing Official	Update	Change Request	Hays, Harry CEO Carroll County Memorial Hospital 5027323200	Dees, Kim CEO Carroll Co Hospital 5027327411	7/17/2019 7:28 AM
Details	Last Recertification Date	Update	Recertification	11/21/2017 3:39:26 PM	8/15/2018 9:42:38 AM	8/15/2018 9:42 AM
Contacts	Primary Contact	Update	Recertification	PARRISH, DAVID CFO 5027323275	Abplanalp, Larry L Director Pharmacy Carroll Co. Hospital 8125992859	11/21/2017 3:39 PM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	11/21/2017 3:39:26 PM	11/21/2017 3:39 PM
Contacts	Authorizing Official	Update		Hays, Harry CEO 5027323200	Hays, Harry CEO Carroll County Memorial Hospital 5027323200	10/2/2017 11:05 AM
Contacts	Authorizing Official	Update		Kozar, Michael A. CEO 5027323200	Hays, Harry CEO 5027323200	9/11/2017 3:29 PM
Contacts	Authorizing Official	Update		PARRISH, DAVID CFO 5027323275	Kozar, Michael A. CEO 5027323200	9/5/2016 8:59 AM
Addresses	Main Address	Insert			309 11TH STREET CARROLLTON, KY 41008	9/2/2016 10:28 AM
Details	Last Recertification Date	Update		8/20/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 10:28 AM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/20/2015 12:00:00 AM	8/20/2015 10:09 AM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	8/7/2014 12:00:00 AM	8/7/2014 3:56 PM
Details	Last Recertification Date	Update			9/9/2013 12:00:00 AM	9/9/2013 9:30 PM
Contacts	Authorizing Official	Insert			PARRISH, DAVID CFO 5027323275	9/27/2011 7:09 PM
Contacts	Primary Contact	Insert			PARRISH, DAVID CFO 5027323275	9/27/2011 7:09 PM
Dates	Participating Approval Date	Update			9/27/2011 12:00:00 AM	9/27/2011 7:09 PM
Details	State	Update		Pending	Active	9/27/2011 7:09 PM
Details	Last Recertification Date	Insert				9/15/2011 9:00 AM
Details	Grant Number	Insert			183985	9/15/2011 9:00 AM
Details	340B ID	Insert			CAH181310-01	9/15/2011 9:00 AM
Details	Is Authorizing Official EHB Data	Insert				9/15/2011 9:00 AM
Dates	Last Date That 340B Drugs Purchased	Insert				9/15/2011 9:00 AM
Details	Medicare Provider Number	Insert			181310	9/15/2011 9:00 AM
Details	Entity Name	Insert			CARROLL COUNTY MEMORIAL HOSPITAL	9/15/2011 9:00 AM
Details	Program Code	Insert			CAH	9/15/2011 9:00 AM
Details	Entity Subname	Insert			CARROLL COUNTY RURAL HEALTH CLINIC	9/15/2011 9:00 AM
Dates	Participating Approval Date	Insert				9/15/2011 9:00 AM
Details	State	Insert			Pending	9/15/2011 9:00 AM
Dates	Registration Date	Insert			9/15/2011 12:00:00 AM	9/15/2011 9:00 AM
Dates	Signed By Date	Insert				9/15/2011 9:00 AM
Dates	Start Date	Insert			10/1/2011 12:00:00 AM	9/15/2011 9:00 AM
Terminations	Termination Comments	Insert				9/15/2011 9:00 AM
Terminations	Termination Date	Insert				9/15/2011 9:00 AM
Terminations	Termination Effective Date	Insert				9/15/2011 9:00 AM
Terminations	Termination Reason	Insert				9/15/2011 9:00 AM