Covered Entity Details

DSH150104C WITHAM MEMORIAL HOSPITAL (Terminated) - information as of 4/25/2025 8:34:07 PM

Main Details

Name

WITHAM MEMORIAL HOSPITAL

Subdivision Name

WITHAM HEALTH SERVICES AT ANSON / Emergency Services

Type

Disproportionate Share Hospital

Rural

340B ID

DSH150104C

Medicare Provider Number

150104

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/3/2020

Participating Start Date

5/19/2020

Participating Approval Date

5/19/2020

Last Recertification Date

9/12/2022

Termination Date
Termination Reason

7/1/2023
DSH percentage below statutory minimum

Contacts

Authorizing Official

Witham Memorial Hospial
George Pogas, SR VP of Finance/CFO
(765) 485-8102

Primary Contact

Witham Health Services
Dana Burton, Controller
(765) 485-8035

Addresses

Street Address

6085 HEARTLAND DR
ZIONSVILLE, IN 46077-4432

Billing Address

Witham Health Services
2605 N Lebanon Street
Lebanon, IN 46052

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating Starting 4/1/15; Terminated 7/1/2019; Reinstated 5/19/2020.	05/19/2020
Participating Starting 4/1/15; Terminated 7/1/2019; Reinstated 7/1/2020.	05/19/2020

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

Witham Health Services
2705 N Lebanon Street
Lebanon, IN 46052

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
DSH150104A	Child	DSH	Witham Memorial Hospital	WITHAM MEMORIAL HOSPITAL / Audiology	2505 N LEBANON ST STE 220	LEBANON	IN	Terminated
DSH150104B	Child	DSH	WITHAM MEMORIAL HOSPITAL	WITHAM HEALTH SERVICES NORTH PAVILI / Wound Care	2705 N LEBANON ST	LEBANON	IN	Terminated
DSH150104C	Child	DSH	WITHAM MEMORIAL HOSPITAL	WITHAM HEALTH SERVICES AT ANSON / Emergency Services	6085 HEARTLAND DR	ZIONSVILLE	IN	Terminated
DSH150104D	Child	DSH	WITHAM MEMORIAL HOSPITAL	WITHAM HEALTH SERVICES AT ANSON / Pain Management	6085 HEARTLAND DR	ZIONSVILLE	IN	Terminated
DSH150104E	Child	DSH	WITHAM MEMORIAL HOSPITAL	Hematology/Oncology Center - Hematology/Oncology	2505 N Lebanon Street	Lebanon	IN	Terminated
DSH150104F	Child	DSH	WITHAM MEMORIAL HOSPITAL	WITHAM HEALTH SERVICES - Pain Management Lebanon	2705 N Lebanon Street	Lebanon	IN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		6/7/2023 12:00:00 AM	6/20/2023 7:44 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/20/2023 7:44 AM
Terminations	Termination Comments	Update	Termination Request		We submitted an appeal. Denial of appeal received on 06/07/2023.	6/20/2023 7:44 AM
Terminations	Termination Date	Update	Termination Request		7/1/2023 12:00:00 AM	6/20/2023 7:44 AM
Terminations	Termination Effective Date	Update	Termination Request		5/31/2023 12:00:00 AM	6/20/2023 7:44 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/20/2023 7:44 AM
Details	Last Recertification Date	Update	Recertification	8/23/2021 9:14:13 AM	9/12/2022 9:23:52 AM	9/12/2022 9:23 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 3:13:42 PM	8/23/2021 9:14:13 AM	8/23/2021 9:14 AM
Details	Last Recertification Date	Update	Recertification		8/26/2020 3:13:42 PM	8/26/2020 3:13 PM
Details	State	Update	OPA Edit	Approved	Active	5/19/2020 2:54 PM
Dates	Start Date	Update	OPA Edit	7/1/2020 12:00:00 AM	5/19/2020 12:00:00 AM	5/19/2020 2:54 PM
Details	Comments Public	Insert	OPA Edit		Participating Starting 4/1/15; Terminated 7/1/2019; Reinstated 5/19/2020.	5/19/2020 2:54 PM
Addresses	Billing Address	Insert	Reinstatement		Witham Health Services 2605 N Lebanon Street Lebanon, IN 46052	5/19/2020 1:50 PM
Details	Last Recertification Date	Update	Reinstatement	8/17/2018 4:09:15 PM		5/19/2020 1:50 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	5/31/2019 12:00:00 AM		5/19/2020 1:50 PM
Details	Entity Name	Update	Reinstatement	Witham Memorial Hospital	WITHAM MEMORIAL HOSPITAL	5/19/2020 1:50 PM
Dates	Participating Approval Date	Update	Reinstatement	3/11/2015 12:00:00 AM	5/19/2020 1:50:10 PM	5/19/2020 1:50 PM
Details	State	Update	Reinstatement	Terminated	Approved	5/19/2020 1:50 PM
Dates	Registration Date	Update	Reinstatement	1/12/2015 12:00:00 AM	4/3/2020 4:50:23 PM	5/19/2020 1:50 PM
Dates	Signed By Date	Update	Reinstatement	1/12/2015 12:00:00 AM	4/3/2020 5:22:46 PM	5/19/2020 1:50 PM
Dates	Start Date	Update	Reinstatement	4/1/2015 12:00:00 AM	7/1/2020 12:00:00 AM	5/19/2020 1:50 PM
Terminations	Termination Date	Update	Reinstatement	7/1/2019 12:00:00 AM		5/19/2020 1:50 PM
Terminations	Termination Effective Date	Update	Reinstatement	5/31/2019 12:00:00 AM		5/19/2020 1:50 PM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		5/19/2020 1:50 PM
Details	Comments Public	Insert	Reinstatement		Participating Starting 4/1/15; Terminated 7/1/2019; Reinstated 7/1/2020.	5/19/2020 1:40 PM
Contacts	Authorizing Official	Update	Reinstatement	Pogas, George SR VP of Finance/CFO Boone County 7654858102	Pogas, George SR VP of Finance/CFO Witham Memorial Hospial 7654858102	4/2/2020 12:32 PM
Contacts	Signed By	Update	Reinstatement	Pogas, George SR VP of Finance/CFO Boone County 7654858102	Pogas, George SR VP of Finance/CFO Witham Memorial Hospial 7654858102	4/2/2020 12:32 PM
Details	State	Update		To Be Terminated	Terminated	7/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		5/31/2019 12:00:00 AM	6/7/2019 10:51 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/7/2019 10:51 AM
Terminations	Termination Date	Update	Termination Request		7/1/2019 12:00:00 AM	6/7/2019 10:51 AM
Terminations	Termination Effective Date	Update	Termination Request		5/31/2019 12:00:00 AM	6/7/2019 10:51 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	6/7/2019 10:51 AM
Details	Last Recertification Date	Update	Recertification	11/3/2017 10:40:06 AM	8/17/2018 4:09:15 PM	8/17/2018 4:09 PM
Details	Entity Name	Update	Recertification	WITHAM MEMORIAL HOSPITAL	Witham Memorial Hospital	11/3/2017 12:00 PM
Contacts	Primary Contact	Update	Recertification	Pogas, George SR VP of Finance/CFO Boone County 7654858102	Burton, Dana Controller Witham Health Services 7654858035	11/3/2017 10:40 AM
Details	Last Recertification Date	Update	Recertification	8/26/2016 12:00:00 AM	11/3/2017 10:40:06 AM	11/3/2017 10:40 AM
Addresses	Main Address	Insert			6085 HEARTLAND DR ZIONSVILLE, IN 46077-4432	8/26/2016 11:28 AM
Contacts	Authorizing Official	Insert			Pogas, George SR VP of Finance/CFO Boone County 7654858102	8/26/2016 11:28 AM
Contacts	Primary Contact	Insert			Pogas, George SR VP of Finance/CFO Boone County 7654858102	8/26/2016 11:28 AM
Contacts	Signed By	Insert			Pogas, George SR VP of Finance/CFO Boone County 7654858102	8/26/2016 11:28 AM
Details	Last Recertification Date	Update		8/12/2015 12:00:00 AM	8/26/2016 12:00:00 AM	8/26/2016 11:28 AM
Details	Last Recertification Date	Update			8/12/2015 12:00:00 AM	8/12/2015 8:44 AM
Addresses	Billing Address	Insert			Witham Health Services 2605 N Lebanon Street Lebanon, IN 46052	3/11/2015 2:54 PM
Addresses	Shipping Address	Insert			Witham Health Services 2705 N Lebanon Street Lebanon, IN 46052	3/11/2015 2:54 PM
Dates	Participating Approval Date	Update			3/11/2015 12:00:00 AM	3/11/2015 2:53 PM
Details	State	Update		Pending	Active	3/11/2015 2:53 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/11/2015 2:53 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_48709	DSH150104C	1/12/2015 2:00 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_48709	1/12/2015 11:52 AM
Details	Last Recertification Date	Insert				1/12/2015 11:52 AM
Details	Grant Number	Insert				1/12/2015 11:52 AM
Details	340B ID	Insert				1/12/2015 11:52 AM
Details	Is Authorizing Official EHB Data	Insert				1/12/2015 11:52 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/12/2015 11:52 AM
Details	Medicare Provider Number	Insert			150104	1/12/2015 11:52 AM
Details	Entity Name	Insert			WITHAM MEMORIAL HOSPITAL	1/12/2015 11:52 AM
Details	Program Code	Insert			DSH	1/12/2015 11:52 AM
Details	Entity Subname	Insert			WITHAM HEALTH SERVICES AT ANSON / Emergency Services	1/12/2015 11:52 AM
Dates	Participating Approval Date	Insert				1/12/2015 11:52 AM
Details	State	Insert			Pending	1/12/2015 11:52 AM
Dates	Registration Date	Insert			1/12/2015 12:00:00 AM	1/12/2015 11:52 AM
Dates	Signed By Date	Insert			1/12/2015 12:00:00 AM	1/12/2015 11:52 AM
Dates	Start Date	Insert				1/12/2015 11:52 AM
Terminations	Termination Comments	Insert				1/12/2015 11:52 AM
Terminations	Termination Date	Insert				1/12/2015 11:52 AM
Terminations	Termination Effective Date	Insert				1/12/2015 11:52 AM
Terminations	Termination Reason	Insert				1/12/2015 11:52 AM