Covered Entity Details

SCH360125-20 Ashtabula County Medical Center (Active) - information as of 5/13/2025 11:04:23 PM

Main Details

Name

Ashtabula County Medical Center

Subdivision Name

Conneaut Family Health Center

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH360125-20

Medicare Provider Number

360125

Outpatient Facility Provider Number

360125

Additional Details

Current Program Status

Active

Registration Date

7/14/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/15/2014

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

ASHTABULA COUNTY MEDICAL CENTER
Alanna Dames, Chief Financial Officer
(440) 997-6553

Primary Contact

ASHTABULA COUNTY MEDICAL CENTER
BARRY H SHICK, Director, Pharmacy
(440) 997-6276

Addresses

Street Address

354 West Main Rd
Conneaut, OH 44030

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
OH	0289343	1285607416,1942247143

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
SCH360125-01	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Orthopedics	2422 LAKE AVE	ASHTABULA	OH	Active
SCH360125-02	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Urology	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-03	Child	SCH	Ashtabula County Medical Center	Psychiatry	2420 Lake Avenue	Ashtabula	OH	Active
SCH360125-04	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Vascular Surgery	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-05	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - ENT	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-06	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - General Surgery	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-07	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Pain Management	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-08	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Neurology	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-09	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Opthalmology	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-10	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Podiatry	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-11	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Rheumatology	2422 Lake Avenue	Ashtabula	OH	Terminated
SCH360125-12	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Pulmonology	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-13	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Endocrinolgy	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-14	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Pediatric Cardiology	2422 Lake Avenue	Ashtabula	OH	Terminated
SCH360125-15	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - OB/GYN High Risk	2422 Lake Avenue	Ashtabula	OH	Terminated
SCH360125-16	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Family Practice	2259 Lake Avenue	Ashtabula	OH	Active
SCH360125-17	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Internal Medicine	2422 Lake Avenue	Ashtabula	OH	Terminated
SCH360125-18	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Pediatrics	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-19	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Cardiology	2422 Lake Avenue	Ashtabula	OH	Active
SCH360125-20	Child	SCH	Ashtabula County Medical Center	Conneaut Family Health Center	354 West Main Rd	Conneaut	OH	Active
SCH360125-21	Child	SCH	Ashtabula County Medical Center	Gastroenterology	2112 Lake Ave	Ashtabula	OH	Active
SCH360125-22	Child	SCH	Ashtabula County Medical Center	Jefferson Family Health Center	234 North Chestnut Street	Jefferson	OH	Active
SCH360125-23	Child	SCH	Ashtabula County Medical Center	Women's Health Clinic	524 West 24th Street	Ashtabula	OH	Terminated
SCH360125-24	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - North Kingsville Office	6441 South Main Street	North Kingsville	OH	Terminated
SCH360125-25	Child	SCH	Ashtabula County Medical Center	ACMC Cancer Center / Oncology / Infusion / Hematology	2412 Lake Avenue	Ashtabula	OH	Active
SCH360125-26	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Primary Care	2825 Lake Avenue	Ashtabula	OH	Terminated
SCH360125-27	Child	SCH	Ashtabula County Medical Center	The Ashtabula Clinic - Harbor Medical Primary Care	1230 Lake Avenue	Ashtabula	OH	Terminated
SCH360125-28	Child	SCH	Ashtabula County Medical Center	Geneva Family Health Center	5201 Spire Cir	Geneva	OH	Active
SCH360125-29	Child	SCH	Ashtabula County Medical Center	ASHTABULA COUNTY MEDICAL CENTER - Orwell Family Health Center	8220 STATE ROUTE 45	ORWELL	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/30/2023 12:57:38 PM	9/6/2024 8:13:10 AM	9/6/2024 8:13 AM
Contacts	Primary Contact	Update	Group Change Request	Shick, Barry H. Director, Pharmacy Services Ashtabula County Medical Center 4409976276	SHICK, BARRY H Director, Pharmacy ASHTABULA COUNTY MEDICAL CENTER 4409976276	7/15/2024 7:47 AM
Contacts	Authorizing Official	Update	Change Request	Trice, Richard VP of Clinical Services Ashtabula County Medical Center 4409976771	Dames, Alanna Chief Financial Officer ASHTABULA COUNTY MEDICAL CENTER 4409976553	10/27/2023 11:40 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 11:18:50 AM	8/30/2023 12:57:38 PM	8/30/2023 12:57 PM
Details	Last Recertification Date	Update	Recertification	9/15/2021 9:23:53 AM	9/1/2022 11:18:50 AM	9/1/2022 11:18 AM
Contacts	Authorizing Official	Update	Change Request	Kepner, Donald L. Chief Financial Officer Ashtabula County Medical Center 4409976912	Trice, Richard VP of Clinical Services Ashtabula County Medical Center 4409976771	6/9/2022 8:26 AM
Contacts	Primary Contact	Update	Recertification	Oakes, Anna-Marie Pharmacy Director Ashtabula County Medical Center 4409976276	Shick, Barry H. Director, Pharmacy Services Ashtabula County Medical Center 4409976276	9/15/2021 9:23 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 8:06:41 AM	9/15/2021 9:23:53 AM	9/15/2021 9:23 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1285607416	8/20/2020 8:06 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/20/2020 8:06 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1942247143	8/20/2020 8:06 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/20/2020 8:06 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1285607416 ( )		8/20/2020 8:06 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1942247143 ( )		8/20/2020 8:06 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 2:31:24 PM	8/20/2020 8:06:41 AM	8/20/2020 8:06 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 5:50:42 PM	9/3/2019 2:31:24 PM	9/3/2019 2:31 PM
Details	Last Recertification Date	Update	Recertification	12/4/2017 6:41:58 AM	9/6/2018 5:50:42 PM	9/6/2018 5:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285607416	2/19/2018 11:10 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1942247143	2/19/2018 11:10 AM
Details	Last Recertification Date	Update	Recertification	8/27/2016 12:00:00 AM	12/4/2017 6:41:58 AM	12/4/2017 6:41 AM
Contacts	Primary Contact	Insert	Change Request		Oakes, Anna-Marie Pharmacy Director Ashtabula County Medical Center 4409976276	10/23/2017 5:31 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	360125	0289343	10/23/2017 4:59 PM
Contacts	Authorizing Official	Update		Kepner, Donald L. Chief Financial Officer 4409976912	Kepner, Donald L. Chief Financial Officer Ashtabula County Medical Center 4409976912	10/4/2017 8:13 AM
Contacts	Signed By	Update		Kepner, Donald L. Chief Financial Officer 4409976912	Kepner, Donald L. Chief Financial Officer Ashtabula County Medical Center 4409976912	10/4/2017 8:13 AM
Contacts	Authorizing Official	Insert			Kepner, Donald L. Chief Financial Officer 4409976912	7/21/2017 10:41 AM
Contacts	Signed By	Insert			Kepner, Donald L. Chief Financial Officer 4409976912	7/21/2017 10:41 AM
Addresses	Main Address	Insert			354 West Main Rd Conneaut, OH 44030	7/20/2017 1:45 PM
Details	Last Recertification Date	Update		8/15/2015 12:00:00 AM	8/27/2016 12:00:00 AM	8/27/2016 8:30 AM
Details	Last Recertification Date	Update			8/15/2015 12:00:00 AM	8/15/2015 7:58 AM
Dates	Participating Approval Date	Update			9/15/2014 12:00:00 AM	9/15/2014 10:17 AM
Details	State	Update		Pending	Active	9/15/2014 10:17 AM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/15/2014 10:17 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45625	SCH360125-20	9/9/2014 9:08 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_45625	7/14/2014 1:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/14/2014 1:40 PM
Medicaid Billing	Medicaid: Number	Insert			360125	7/14/2014 1:40 PM
Medicaid Billing	Medicaid: State	Insert			OH	7/14/2014 1:40 PM
Details	Last Recertification Date	Insert				7/14/2014 1:40 PM
Details	Grant Number	Insert				7/14/2014 1:40 PM
Details	340B ID	Insert				7/14/2014 1:40 PM
Details	Is Authorizing Official EHB Data	Insert				7/14/2014 1:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/14/2014 1:40 PM
Details	Medicare Provider Number	Insert			360125	7/14/2014 1:40 PM
Details	Entity Name	Insert			Ashtabula County Medical Center	7/14/2014 1:40 PM
Details	Program Code	Insert			SCH	7/14/2014 1:40 PM
Details	Entity Subname	Insert			Conneaut Family Health Center	7/14/2014 1:40 PM
Dates	Participating Approval Date	Insert				7/14/2014 1:40 PM
Details	State	Insert			Pending	7/14/2014 1:40 PM
Dates	Registration Date	Insert			7/14/2014 12:00:00 AM	7/14/2014 1:40 PM
Dates	Signed By Date	Insert			7/14/2014 12:00:00 AM	7/14/2014 1:40 PM
Dates	Start Date	Insert				7/14/2014 1:40 PM
Terminations	Termination Comments	Insert				7/14/2014 1:40 PM
Terminations	Termination Date	Insert				7/14/2014 1:40 PM
Terminations	Termination Effective Date	Insert				7/14/2014 1:40 PM
Terminations	Termination Reason	Insert				7/14/2014 1:40 PM