Covered Entity Details

DSH180036A OUR LADY OF BELLEFONTE HOSPITAL (Terminated) - information as of 6/16/2025 11:14:52 PM

Main Details

Name

OUR LADY OF BELLEFONTE HOSPITAL

Subdivision Name

Outpatient Infusion Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH180036A

Medicare Provider Number

180036

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/12/2013

Participating Start Date

7/1/2013

Participating Approval Date

6/11/2013

Last Recertification Date

9/11/2019

Termination Date
Termination Reason

7/1/2020
Site closure

Contacts

Authorizing Official

Bon Secours Mercy Health System
Tyler Walters, Chief Financial Officer
(606) 833-3913

Primary Contact

Bon Secours
Coley W Deal, 340B Program Manager
(804) 221-4837

Addresses

Street Address

200 St. Christopher Drive
Ashland, KY 41101

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
KY	01000082
OH	6639203
WV	0001612000
		1437156346

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
DSH180036A	Child	DSH	OUR LADY OF BELLEFONTE HOSPITAL	Outpatient Infusion Center	200 St. Christopher Drive	Ashland	KY	Terminated
DSH180036B	Child	DSH	OUR LADY OF BELLEFONTE HOSPITAL	Ashland Outpatient Infusion Center	2930 Carter Avenue	Ashland	KY	Terminated
DSH180036C	Child	DSH	OUR LADY OF BELLEFONTE HOSPITAL	Ambulatory Surgery Center	1101 St. Christopher Drive	Ashland	KY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		4/1/2020 12:00:00 AM	4/2/2020 8:46 AM
Details	State	Update	Termination Request	Active	To Be Terminated	4/2/2020 8:46 AM
Terminations	Termination Comments	Update	Termination Request		Hospital closure scheduled for 4/30/2020.	4/2/2020 8:46 AM
Terminations	Termination Date	Update	Termination Request		7/1/2020 12:00:00 AM	4/2/2020 8:46 AM
Terminations	Termination Effective Date	Update	Termination Request		4/1/2020 12:00:00 AM	4/2/2020 8:46 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	4/2/2020 8:46 AM
Details	Last Recertification Date	Update	Recertification	9/11/2018 8:49:39 AM	9/11/2019 10:21:53 AM	9/11/2019 10:21 AM
Contacts	Authorizing Official	Update	Change Request	Halter, Kevin CEO Bon Secours 6068333600	Walters, Tyler Chief Financial Officer Bon Secours Mercy Health System 6068333913	4/29/2019 4:14 PM
Details	Last Recertification Date	Update	Recertification	11/30/2017 4:39:40 PM	9/11/2018 8:49:39 AM	9/11/2018 8:49 AM
Contacts	Primary Contact	Update	Recertification	Deal, Coley 340B Program Manager Bon Secours 8042214837	Deal, Coley W 340B Program Manager Bon Secours 8042214837	12/5/2017 2:38 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	11/30/2017 4:39:40 PM	11/30/2017 4:39 PM
Contacts	Authorizing Official	Update		Halter, Kevin CEO 6068333600	Halter, Kevin CEO Bon Secours 6068333600	9/28/2017 9:57 AM
Contacts	Signed By	Update		Halter, Kevin CEO 6068333600	Halter, Kevin CEO Bon Secours 6068333600	9/28/2017 9:57 AM
Contacts	Primary Contact	Update		Deal, Coley 340B Program Manager 8042214837	Deal, Coley 340B Program Manager Bon Secours 8042214837	9/27/2017 5:02 PM
Contacts	Authorizing Official	Insert			Halter, Kevin CEO 6068333600	8/14/2017 11:06 AM
Contacts	Signed By	Insert			Halter, Kevin CEO 6068333600	8/14/2017 11:06 AM
Contacts	Primary Contact	Update		Lyons, Gerry Director of Pharmacy 6068333121	Deal, Coley 340B Program Manager 8042214837	8/14/2017 11:06 AM
Addresses	Main Address	Insert			200 St. Christopher Drive Ashland, KY 41101	8/14/2017 11:06 AM
Contacts	Primary Contact	Insert			Lyons, Gerry Director of Pharmacy 6068333121	1/22/2017 3:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/8/2016 4:40 PM
Medicaid Billing	Medicaid: Number	Insert			0001612000	12/8/2016 4:40 PM
Medicaid Billing	Medicaid: State	Insert			WV	12/8/2016 4:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	11/8/2016 4:41 PM
Medicaid Billing	Medicaid: Number	Insert			6639203	11/8/2016 4:41 PM
Medicaid Billing	Medicaid: State	Insert			OH	11/8/2016 4:41 PM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 7:44 AM
Details	Last Recertification Date	Update		9/10/2014 12:00:00 AM	8/31/2015 12:00:00 AM	8/31/2015 9:33 AM
Details	Last Recertification Date	Update		9/10/2013 9:43:55 AM	9/10/2014 12:00:00 AM	9/10/2014 4:02 PM
Details	Last Recertification Date	Update			9/10/2013 9:43:55 AM	9/10/2013 9:43 AM
Details	340B ID	Update		IS-FF-DSH180036A	DSH180036A	6/11/2013 9:03 AM
Dates	Participating Approval Date	Update			6/11/2013 12:00:00 AM	6/11/2013 9:03 AM
Details	State	Update		Pending	Active	6/11/2013 9:03 AM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	6/11/2013 9:03 AM
Details	340B ID	Update		FF041413G	IS-FF-DSH180036A	5/10/2013 4:19 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	FF041413G	4/14/2013 7:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/12/2013 1:27 PM
Medicaid Billing	Medicaid: Number	Insert			01000082	4/12/2013 1:27 PM
Medicaid Billing	Medicaid: State	Insert			KY	4/12/2013 1:27 PM
Medicaid Billing	NPI: Number	Insert			1437156346	4/12/2013 1:27 PM
Details	Last Recertification Date	Insert				4/12/2013 1:27 PM
Details	Grant Number	Insert				4/12/2013 1:27 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/12/2013 1:27 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2013 1:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2013 1:27 PM
Details	Medicare Provider Number	Insert			180036	4/12/2013 1:27 PM
Details	Entity Name	Insert			OUR LADY OF BELLEFONTE HOSPITAL	4/12/2013 1:27 PM
Details	Program Code	Insert			DSH	4/12/2013 1:27 PM
Details	Entity Subname	Insert			Outpatient Infusion Center	4/12/2013 1:27 PM
Dates	Participating Approval Date	Insert				4/12/2013 1:27 PM
Details	State	Insert			Pending	4/12/2013 1:27 PM
Dates	Registration Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 1:27 PM
Dates	Signed By Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 1:27 PM
Dates	Start Date	Insert				4/12/2013 1:27 PM
Terminations	Termination Comments	Insert				4/12/2013 1:27 PM
Terminations	Termination Date	Insert				4/12/2013 1:27 PM
Terminations	Termination Effective Date	Insert				4/12/2013 1:27 PM
Terminations	Termination Reason	Insert				4/12/2013 1:27 PM