Covered Entity Details

CAH361302-00 TRINITY HOSPITAL TWIN CITY (Active) - information as of 5/13/2025 1:39:47 AM

Main Details

Name

TRINITY HOSPITAL TWIN CITY

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH361302-00

Medicare Provider Number

361302

Additional Details

Current Program Status

Active

Registration Date

4/1/2013

Participating Start Date

7/1/2013

Participating Approval Date

4/26/2013

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Trinity Health System
Dave Werkin, CFO
(740) 264-8695

Primary Contact

Trinity Hospital Twin CIty
Eric Durbin, Director of Pharmacy
(740) 922-7467

Addresses

Street Address

819 N 1st STREET
DENNISON, OH 44621-1003

Billing Address

TRINITY HOSPITAL TWIN CITY
PO BOX 2400
Phoenix, AZ 85002-6000

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
OH	0053773	1992096192,1083052906

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	AHSSHC	EXPEDIEN RX PHARMACY	5050 WESLEY RD STE 120	APOPKA	FL	32712	10/11/2016	01/01/2017	05/10/2017	05/23/2017
Contract Detail	BELMONT COUNTY HEALTH SERVICES, INC.	DBA CUSTER PHARMACY	241 S MAIN ST	CADIZ	OH	43907	01/02/2019	04/01/2019	04/30/2024	06/27/2024
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	CUSTER PHARMACY	241 SOUTH MAIN STREET		CADIZ	OH	43907	10/02/2014	01/01/2015	10/15/2018	10/16/2018
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	04/15/2018	07/01/2018	12/31/2018	01/08/2019
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/09/2018	07/01/2018	12/07/2020	12/09/2020
Contract Detail	DELIVERCARERX PHARMACY LLC	DELIVERCARERX PHARMACY LLC	1471 E BUSINESS CENTER DR STE 200	MT PROSPECT	IL	60056	10/13/2016	01/01/2017	05/10/2017	05/23/2017
Contract Detail	DISCOUNT DRUG MART #52	3015 NORTH WOOSTER AVENUE		DOVER	OH	44622	01/14/2014	04/01/2014		01/14/2014
Contract Detail	DISCOUNT DRUG MART INC	STORE #26	238 2ND STREET NW	NEW PHILADELPHIA	OH	44663	01/14/2014	04/01/2014		01/14/2014
Contract Detail	DUSINI DRUG INC	315 E HIGH AVE		NEW PHILADELPHIA	OH	44663-2566	10/02/2014	01/01/2015	06/26/2017	06/26/2017
Contract Detail	GIANT EAGLE PHARMACY #4089	515 UNION AVENUE		DOVER	OH	44622	01/18/2016	04/01/2016	06/01/2018	06/08/2018
Contract Detail	MEDICINE CENTER PHARMACY	551 W HIGH AVE		NEW PHILADELPHIA	OH	44663-2005	10/04/2013	01/01/2014		10/04/2013
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 04353	300 OXFORD ST.,	DOVER	OH	44622	01/14/2014	04/01/2014		01/14/2014
Contract Detail	OHIO CVS STORES, L.L.C.	CVS/PHARMACY # 10961	21 GRANT ST.	DENNISON	OH	44621	07/15/2020	10/01/2020		10/01/2020
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03455	200 SOUTH SECOND STREET	COSHOCTON	OH	43812	07/15/2020	10/01/2020		10/01/2020
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	OPTUM PHARMACY 800, INC.	3016 GUADALUPE ST STE A		AUSTIN	TX	78705-2861	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	07/15/2019	10/01/2019	01/31/2021	02/24/2021
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/09/2018	07/01/2018	12/07/2020	12/09/2020
Contract Detail	RITE AID OF OHIO, INC.	RITE AID #4247	218 CHESTNUT STREET	COSHOCTON	OH	43812	01/03/2014	04/01/2014	08/15/2024	09/23/2024
Contract Detail	RITE AID OF OHIO, INC.	RITE AID #1793	651 LINCOLN STREET	CADIZ	OH	43907	07/11/2014	10/01/2014	08/15/2024	09/23/2024
Contract Detail	RITZMAN PHARMACY #210	3000 N WOOSTER AVE		DOVER	OH	44622-9469	04/14/2014	07/01/2014	12/31/2018	01/02/2019
Contract Detail	ROSS PARK PHARMACY	1 ROSS PARK BLVD		STEUBENVILLE	OH	43952-2681	01/02/2019	04/01/2019	06/05/2021	06/05/2021
Contract Detail	ROSS PARK PHARMACY WEST	4100 JOHNSON RD	STE 105	STEUBENVILLE	OH	43952-2356	01/02/2019	04/01/2019	06/05/2021	06/05/2021
Contract Detail	THE LANE DRUG COMPANY	RITE AID #2414	735 NORTH WATER STREET	UHRICHSVILLE	OH	44683	05/01/2013	07/01/2013		05/01/2013
Contract Detail	THE LANE DRUG COMPANY	RITE AID #2392	705 WEST HIGH AVENUE	NEW PHILADELPHIA	OH	44663	05/01/2013	07/01/2013	08/15/2024	09/23/2024
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/06/2017	01/01/2018		10/06/2017
Contract Detail	WAL-MART PHARMACY 10-1937	23605 AIRPORT RD		COSHOCTON	OH	43812	01/07/2014	04/01/2014		01/07/2014
Contract Detail	WAL-MART PHARMACY 10-2115	231 BLUEBELL DR NW.		NEW PHILADELPHIA	OH	44663	01/07/2014	04/01/2014		01/07/2014
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/06/2017	01/01/2018		10/06/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11694	190 CHESTNUT ST.	COSHOCTON	OH	43812	04/09/2018	07/01/2018		04/09/2018
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16529	375 S MAIN ST SUITE 108	AKRON	OH	44311	04/09/2018	07/01/2018		04/09/2018
Contract Detail	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	10/08/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	04/09/2018	07/01/2018		04/09/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/09/2018	07/01/2018	12/07/2020	12/09/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/09/2018	07/01/2018	12/07/2020	12/09/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/09/2018	07/01/2018	12/31/2018	01/08/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/09/2018	07/01/2018	12/31/2018	01/08/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/09/2018	07/01/2018	12/07/2020	12/09/2020
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	04/09/2018	07/01/2018		04/09/2018
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/03/2024	07/01/2024		07/01/2024
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	04/03/2024	07/01/2024		07/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH361302-01	Child	CAH	TRINITY HOSPITAL TWIN CITY	TRINITY MEDICAL GROUP	223 W Main St	NEWCOMERSTOWN	OH	Active
CAH361302-02	Child	CAH	TRINITY HOSPITAL TWIN CITY	TRINITY MEDICAL GROUP / Surgical Clinic	340 OXFORD STREET	DOVER	OH	Active
CAH361302-03	Child	CAH	TRINITY HOSPITAL TWIN CITY	GNADEN	110 North Walnut Street	Gnadenhutten	OH	Active
CAH361302-04	Child	CAH	TRINITY HOSPITAL TWIN CITY	TRINITY MEDICAL GROUP	6408 McKee Road	Dennison	OH	Active
CAH361302-05	Child	CAH	TRINITY HOSPITAL TWIN CITY	TRINITY MEDICAL GROUP / TMG Primary Care	340 OXFORD STREET	DOVER	OH	Active
CAH361302-06	Child	CAH	TRINITY HOSPITAL TWIN CITY	TMG Coshocton 2	435 Walnut Street	Coshocton	OH	Terminated
CAH361302-07	Child	CAH	TWIN CITY HOSPITAL	Trinity Medical Group Coshocton 1	650 Chestnut Street	Coshocton	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Change Request	DURBIN, ERIC PHARMACIST Trinity Hospital Twin City 7409222800-2286	Durbin, Eric Director of Pharmacy Trinity Hospital Twin CIty 7409227467	3/21/2025 9:56 AM
Details	Last Recertification Date	Update	Recertification	8/16/2023 7:13:08 AM	8/15/2024 7:02:13 AM	8/15/2024 7:02 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 8:02:07 AM	8/16/2023 7:13:08 AM	8/16/2023 7:13 AM
Addresses	Billing Address	Update	Change Request	TRINITY HOSPITAL TWIN CITY PO BOX 636000 LITTLETON, CO 80163-6000	TRINITY HOSPITAL TWIN CITY PO BOX 2400 Phoenix, AZ 85002-6000	7/24/2023 11:01 AM
Addresses	Billing Address	Insert	Change Request		TRINITY HOSPITAL TWIN CITY PO BOX 636000 LITTLETON, CO 80163-6000	6/29/2023 8:19 AM
Details	Last Recertification Date	Update	Recertification	8/23/2021 9:31:13 AM	9/16/2022 8:02:07 AM	9/16/2022 8:02 AM
Details	Last Recertification Date	Update	Recertification	9/10/2020 3:13:28 PM	8/23/2021 9:31:13 AM	8/23/2021 9:31 AM
Medicaid Billing	NPI: State	Update	Recertification		OH	9/10/2020 3:13 PM
Medicaid Billing	NPI: State	Update	Recertification		OH	9/10/2020 3:13 PM
Details	Last Recertification Date	Update	Recertification	9/2/2019 12:03:06 PM	9/10/2020 3:13:28 PM	9/10/2020 3:13 PM
Details	Last Recertification Date	Update	Recertification	8/29/2018 9:39:21 AM	9/2/2019 12:03:06 PM	9/2/2019 12:03 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 11:55:57 AM	8/29/2018 9:39:21 AM	8/29/2018 9:39 AM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/29/2017 11:55:57 AM	11/29/2017 11:55 AM
Contacts	Authorizing Official	Update		Werkin, Dave CFO 7402648695	Werkin, Dave CFO Trinity Health System 7402648695	10/6/2017 6:58 AM
Contacts	Primary Contact	Update		DURBIN, ERIC PHARMACIST 7409222800-2286	DURBIN, ERIC PHARMACIST Trinity Hospital Twin City 7409222800-2286	9/19/2017 11:33 AM
Contacts	Signed By	Insert			HATHAWAY JR., WOODROW W. CHIEF FINANCIAL OFFICER 7409227450-2190	6/26/2017 1:17 PM
Addresses	Main Address	Insert			819 N 1st STREET DENNISON, OH 44621-1003	6/6/2017 10:34 AM
Contacts	Authorizing Official	Update		MITCHELL, JOSEPH PRESIDENT 7409227450-2218	Werkin, Dave CFO 7402648695	6/6/2017 10:34 AM
Contacts	Primary Contact	Insert			DURBIN, ERIC PHARMACIST 7409222800-2286	6/6/2017 10:34 AM
Contacts	Authorizing Official	Insert			MITCHELL, JOSEPH PRESIDENT 7409227450-2218	3/8/2017 2:34 PM
Details	Last Recertification Date	Update		8/11/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 3:33 PM
Medicaid Billing	NPI: Number	Insert			1083052906	10/16/2015 8:04 AM
Details	Last Recertification Date	Update		8/11/2014 12:00:00 AM	8/11/2015 12:00:00 AM	8/13/2015 1:41 PM
Details	Last Recertification Date	Update		8/19/2013 12:05:00 PM	8/11/2014 12:00:00 AM	8/11/2014 10:30 AM
Details	Last Recertification Date	Update			8/19/2013 12:05:00 PM	8/19/2013 12:05 PM
Details	340B ID	Update		ISDMCAH361302-00	CAH361302-00	4/26/2013 3:42 PM
Dates	Participating Approval Date	Update			4/26/2013 12:00:00 AM	4/26/2013 3:42 PM
Details	State	Update		Pending	Active	4/26/2013 3:42 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	4/26/2013 3:42 PM
Details	340B ID	Update		DM040213	ISDMCAH361302-00	4/12/2013 9:59 AM
Details	340B ID	Update		DM-040113	DM040213	4/2/2013 7:26 AM
Details	340B ID	Update		DM040113	DM-040113	4/1/2013 2:43 PM
Details	340B ID	Update		ONLINE_REG	DM040113	4/1/2013 12:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/1/2013 9:31 AM
Medicaid Billing	Medicaid: Number	Insert			0053773	4/1/2013 9:31 AM
Medicaid Billing	Medicaid: State	Insert			OH	4/1/2013 9:31 AM
Medicaid Billing	NPI: Number	Insert			1992096192	4/1/2013 9:31 AM
Details	Last Recertification Date	Insert				4/1/2013 9:31 AM
Details	Grant Number	Insert				4/1/2013 9:31 AM
Details	340B ID	Insert			ONLINE_REG	4/1/2013 9:31 AM
Details	Is Authorizing Official EHB Data	Insert				4/1/2013 9:31 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/1/2013 9:31 AM
Details	Medicare Provider Number	Insert			361302	4/1/2013 9:31 AM
Details	Entity Name	Insert			TRINITY HOSPITAL TWIN CITY	4/1/2013 9:31 AM
Details	Program Code	Insert			CAH	4/1/2013 9:31 AM
Details	Entity Subname	Insert				4/1/2013 9:31 AM
Dates	Participating Approval Date	Insert				4/1/2013 9:31 AM
Details	State	Insert			Pending	4/1/2013 9:31 AM
Dates	Registration Date	Insert			4/1/2013 12:00:00 AM	4/1/2013 9:31 AM
Dates	Signed By Date	Insert			4/1/2013 12:00:00 AM	4/1/2013 9:31 AM
Dates	Start Date	Insert				4/1/2013 9:31 AM
Terminations	Termination Comments	Insert				4/1/2013 9:31 AM
Terminations	Termination Date	Insert				4/1/2013 9:31 AM
Terminations	Termination Effective Date	Insert				4/1/2013 9:31 AM
Terminations	Termination Reason	Insert				4/1/2013 9:31 AM