Covered Entity Details

DSH360054CP HOLZER (Terminated) - information as of 5/17/2025 10:50:51 PM

Main Details

Name

HOLZER

Subdivision Name

HOLZER / Lawrence County Radiology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360054CP

Medicare Provider Number

360054

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/14/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/4/2015

Last Recertification Date

8/18/2016

Termination Date
Termination Reason

1/1/2018
Business decision by the Covered Entity

Contacts

Authorizing Official

Holzer
Michael P Haynes, EVP/CFO
(740) 446-5743

Primary Contact

Holzer
Mary Ann Clemente, 340B Compliance Analyst
(740) 446-5803

Addresses

Street Address

98 STATE ST
PROCTORVILLE, OH 45669-8163

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	4046562

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
DSH360054A	Child	DSH	HOLZER	Holzer Diagnostic Testing Center-Gallipolis	90 Jackson Pike	Gallipolis	OH	Terminated
DSH360054AA	Child	DSH	HOLZER	Holzer / Main Podiatry	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AB	Child	DSH	HOLZER	Holzer / Main Cardiology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AC	Child	DSH	HOLZER	Holzer / Main Internal Medicine	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AD	Child	DSH	HOLZER	Holzer / Main Family Practice	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AE	Child	DSH	HOLZER	Holzer / Main PM&R	100 Jackson Pike	Gallipolis	OH	Terminated
DSH360054AF	Child	DSH	HOLZER	Holzer / Main Allergy	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AG	Child	DSH	HOLZER	Albany Family Practice	2364 Blizzard Lane	Albany	OH	Terminated
DSH360054AH	Child	DSH	HOLZER	Holzer / Main Audiology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AJ	Child	DSH	HOLZER	Holzer / Main Neurology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AK	Child	DSH	HOLZER	Holzer / Main Rheumatology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AL	Child	DSH	HOLZER	Holzer / Main Pediatrics	100 Jackson Pike	Gallipolis	OH	Active
DSH360054AM	Child	DSH	HOLZER	HOLZER / Pulmonology	2131E STATE ST	ATHENS	OH	Terminated
DSH360054AN	Child	DSH	HOLZER	HOLZER / Athens PM&R	2131E STATE ST	ATHENS	OH	Terminated
DSH360054AP	Child	DSH	HOLZER	HOLZER / Plastic Surgery	2131E STATE ST	ATHENS	OH	Terminated
DSH360054AQ	Child	DSH	HOLZER	HOLZER / Athens ENT	2131E STATE ST	ATHENS	OH	Active
DSH360054AR	Child	DSH	HOLZER	HOLZER / Athens Orthopedics	2131E STATE ST	ATHENS	OH	Active
DSH360054AS	Child	DSH	HOLZER	HOLZER / Athens Ophthamology	2131E STATE ST	ATHENS	OH	Active
DSH360054AT	Child	DSH	HOLZER	HOLZER / Athens OB/GYN	2131E STATE ST	ATHENS	OH	Active
DSH360054AU	Child	DSH	HOLZER	HOLZER / Athens Gastroenterology	2131E STATE ST	ATHENS	OH	Active
DSH360054AV	Child	DSH	HOLZER	HOLZER / Dermatology	2131E STATE ST	ATHENS	OH	Terminated
DSH360054AW	Child	DSH	HOLZER	HOLZER / Athens General Surgery	2131E STATE ST	ATHENS	OH	Active
DSH360054AX	Child	DSH	HOLZER	HOLZER / Athens Urgent Care	2131E STATE ST	ATHENS	OH	Active
DSH360054AY	Child	DSH	HOLZER	HOLZER / Athens Sleep Medicine	2131E STATE ST	ATHENS	OH	Active
DSH360054AZ	Child	DSH	HOLZER	HOLZER / Nephrology	2131E STATE ST	ATHENS	OH	Terminated
DSH360054B	Child	DSH	HOLZER	Holzer / Jackson Ambulatory Surgery Center	280 Pattonsville Road	Jackson	OH	Active
DSH360054BA	Child	DSH	HOLZER	HOLZER / Athens Podiatry	2131E STATE ST	ATHENS	OH	Active
DSH360054BB	Child	DSH	HOLZER	HOLZER / Jackson Chiropractic	2131E STATE ST	ATHENS	OH	Terminated
DSH360054BC	Child	DSH	HOLZER	HOLZER / Athens Cardiology	2131E STATE ST	ATHENS	OH	Active
DSH360054BD	Child	DSH	HOLZER	HOLZER / Athens Internal Medicine	2131E STATE ST	ATHENS	OH	Active
DSH360054BE	Child	DSH	HOLZER	HOLZER / Athens Family Practice	2131E STATE ST	ATHENS	OH	Active
DSH360054BF	Child	DSH	HOLZER	HOLZER / Athens Allergy	2131E STATE ST	ATHENS	OH	Active
DSH360054BG	Child	DSH	HOLZER	HOLZER / Hematology/Oncology	2131E STATE ST	ATHENS	OH	Terminated
DSH360054BH	Child	DSH	HOLZER	HOLZER / Audiology	2131E STATE ST	ATHENS	OH	Terminated
DSH360054BJ	Child	DSH	HOLZER	HOLZER / Athens Pediatrics	2131E STATE ST	ATHENS	OH	Active
DSH360054BK	Child	DSH	HOLZER	HOLZER / Athens Infusion	2131E STATE ST	ATHENS	OH	Terminated
DSH360054BL	Child	DSH	HOLZER	HOLZER / Urology	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054BM	Child	DSH	HOLZER	HOLZER / Plastic Surgery	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054BN	Child	DSH	HOLZER	HOLZER / Jackson ENT	280 PATTONSVILLE RD	JACKSON	OH	Active
DSH360054BP	Child	DSH	HOLZER	HOLZER / Orthopedics	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054BQ	Child	DSH	HOLZER	HOLZER / Jackson Ophthalmology	280 PATTONSVILLE RD	JACKSON	OH	Active
DSH360054BR	Child	DSH	HOLZER	HOLZER / Jackson OB/GYN	280 PATTONSVILLE RD	JACKSON	OH	Active
DSH360054BS	Child	DSH	HOLZER	HOLZER / Jackson General Surgery	280 PATTONSVILLE RD	JACKSON	OH	Active
DSH360054BT	Child	DSH	HOLZER	HOLZER / Endocrinology	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054BU	Child	DSH	HOLZER	HOLZER / Jackson Urgent Care	280 PATTONSVILLE RD	JACKSON	OH	Active
DSH360054BV	Child	DSH	HOLZER	HOLZER / Jackson Sleep Center	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054BW	Child	DSH	HOLZER	HOLZER / Nephrology	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054BX	Child	DSH	HOLZER	HOLZER / Jackson Chiropractic	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054BY	Child	DSH	HOLZER	HOLZER / Jackson Cardiology	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054BZ	Child	DSH	HOLZER	HOLZER / Jackson Internal Medicine	280 PATTONSVILLE RD	JACKSON	OH	Active
DSH360054C	Child	DSH	HOLZER	Holzer Athens Ambulatory Surgery Center	2131 East State Street	Athens	OH	Active
DSH360054CA	Child	DSH	HOLZER	HOLZER / Jackson Family Practice	280 PATTONSVILLE RD	JACKSON	OH	Active
DSH360054CB	Child	DSH	HOLZER	HOLZER / PM&R	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054CC	Child	DSH	HOLZER	HOLZER / Hematology/Oncology	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054CD	Child	DSH	HOLZER	HOLZER / Audiology	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054CE	Child	DSH	HOLZER	HOLZER / Jackson Pediatrics	280 PATTONSVILLE RD	JACKSON	OH	Active
DSH360054CF	Child	DSH	HOLZER	HOLZER / Radiology	96 TOWNSHIP ROAD 369	PROCTORVILLE	OH	Terminated
DSH360054CG	Child	DSH	HOLZER	HOLZER / Neurology	98 STATE ST	PROCTORVILLE	OH	Terminated
DSH360054CH	Child	DSH	HOLZER	HOLZER / PM&R	98 STATE ST	PROCTORVILLE	OH	Terminated
DSH360054CJ	Child	DSH	HOLZER	HOLZER / Family Practice	98 STATE ST	PROCTORVILLE	OH	Terminated
DSH360054CK	Child	DSH	HOLZER	HOLZER / Internal Medicine	98 STATE ST	PROCTORVILLE	OH	Terminated
DSH360054CL	Child	DSH	HOLZER	HOLZER / Gastroenterology	98 STATE ST	PROCTORVILLE	OH	Terminated
DSH360054CM	Child	DSH	HOLZER	HOLZER / Sleep Medicine	96 TOWNSHIP ROAD 369	PROCTORVILLE	OH	Terminated
DSH360054CN	Child	DSH	HOLZER	HOLZER / Audiology	96 TOWNSHIP ROAD 369	PROCTORVILLE	OH	Terminated
DSH360054CP	Child	DSH	HOLZER	HOLZER / Lawrence County Radiology	98 STATE ST	PROCTORVILLE	OH	Terminated
DSH360054CQ	Child	DSH	HOLZER	HOLZER / Radiology	88E MEMORIAL DR	POMEROY	OH	Terminated
DSH360054CR	Child	DSH	HOLZER	HOLZER / Meigs Family Practice	88E MEMORIAL DR	POMEROY	OH	Active
DSH360054CS	Child	DSH	HOLZER	HOLZER / Meigs Internal Medicine	88E MEMORIAL DR	POMEROY	OH	Active
DSH360054CT	Child	DSH	HOLZER	HOLZER / Meigs Cardiology	88E MEMORIAL DR	POMEROY	OH	Active
DSH360054CU	Child	DSH	HOLZER	HOLZER / Chiropractic	88E MEMORIAL DR	POMEROY	OH	Terminated
DSH360054CV	Child	DSH	HOLZER	HOLZER / Meigs Orthopedics	88E MEMORIAL DR	POMEROY	OH	Active
DSH360054CW	Child	DSH	HOLZER	HOLZER / Pulmonology	88E MEMORIAL DR	POMEROY	OH	Terminated
DSH360054CX	Child	DSH	HOLZER	HOLZER / Meigs Pediatrics	88E MEMORIAL DR	POMEROY	OH	Active
DSH360054CY	Child	DSH	HOLZER	HOLZER / Meigs OB/GYN	88E MEMORIAL DR	POMEROY	OH	Active
DSH360054CZ	Child	DSH	HOLZER	HOLZER / Meigs Urgent Care	88E MEMORIAL DR	POMEROY	OH	Active
DSH360054D	Child	DSH	HOLZER	Holzer/ Main Ambulatory Surgery Center	90 Jackson Pike	Gallipolis	OH	Active
DSH360054DA	Child	DSH	HOLZER	HOLZER / Radiology	1051 4TH AVE	GALLIPOLIS	OH	Terminated
DSH360054DB	Child	DSH	HOLZER	HOLZER / Sycamore Family Practice	1051 4TH AVE	GALLIPOLIS	OH	Active
DSH360054DC	Child	DSH	HOLZER	HOLZER / Sycamore Internal Medicine	1051 4TH AVE	GALLIPOLIS	OH	Terminated
DSH360054DD	Child	DSH	HOLZER	HOLZER / Sycamore Cardiology	1051 4TH AVE	GALLIPOLIS	OH	Terminated
DSH360054DE	Child	DSH	HOLZER	HOLZER / Chiropractic	1051 4TH AVE	GALLIPOLIS	OH	Terminated
DSH360054DF	Child	DSH	HOLZER	HOLZER / Sycamore Occupational Medicine	1051 4TH AVE	GALLIPOLIS	OH	Terminated
DSH360054DG	Child	DSH	HOLZER	HOLZER / Pulmonology	1051 4TH AVE	GALLIPOLIS	OH	Terminated
DSH360054DH	Child	DSH	HOLZER	HOLZER / Sycamore Sleep Medicine	1051 4TH AVE	GALLIPOLIS	OH	Active
DSH360054DJ	Child	DSH	HOLZER	HOLZER / Radiation Oncology - Cancer Cntr	170 JACKSON PIKE	GALLIPOLIS	OH	Active
DSH360054DK	Child	DSH	HOLZER	HOLZER / Sleep Center	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054DL	Child	DSH	HOLZER	HOLZER / Pulmonology	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054DM	Child	DSH	HOLZER	HOLZER / Rheumatology	96 TOWNSHIP ROAD 369	PROCTORVILLE	OH	Terminated
DSH360054DN	Child	DSH	HOLZER	HOLZER - Holzer Meigs Emergency Department	41861 POMEROY PIKE	POMEROY	OH	Active
DSH360054DP	Child	DSH	HOLZER	Holzer / Main Vein Center	100 Jackson Pike	Gallipolis	OH	Active
DSH360054DQ	Child	DSH	HOLZER	Holzer / Main Pain Management	100 Jackson Pike	Gallipolis	OH	Active
DSH360054DR	Child	DSH	HOLZER	HOLZER - Athens Pain Management	2131E STATE ST	ATHENS	OH	Active
DSH360054DS	Child	DSH	HOLZER	HOLZER - Athens Occ Med	2131E STATE ST	ATHENS	OH	Terminated
DSH360054DT	Child	DSH	HOLZER	HOLZER - Jackson Gastro	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054DU	Child	DSH	HOLZER	HOLZER - Jackson Podiatry	280 PATTONSVILLE RD	JACKSON	OH	Terminated
DSH360054DV	Child	DSH	HOLZER	Holzer / Main Wound Care	100 Jackson Pike	Gallipolis	OH	Active
DSH360054DW	Child	DSH	HOLZER	Holzer/Athens Neurology - Athens Neurology	2131 E. State Street	Athens	OH	Active
DSH360054DX	Child	DSH	HOLZER	Holzer/Meigs Podiatry - Meigs Podiatry	88 E. Memorial Drive	Pomeroy	OH	Active
DSH360054DY	Child	DSH	HOLZER	Holzer/Sycamore Podiatry - Sycamore Podiatry	1051 4th Avenue	Gallipolis	OH	Active
DSH360054DZ	Child	DSH	HOLZER	Holzer/Main Behavioral Health - Behavioral Health	100 Jackson Pike	Gallipolis	OH	Active
DSH360054E	Child	DSH	HOLZER	Holzer Center for Cancer Care	170 Jackson Pike	Gallipolis	OH	Active
DSH360054F	Child	DSH	HOLZER	Holzer Hospice	100 Jackson Pike	Gallipolis	OH	Terminated
DSH360054G	Child	DSH	HOLZER	Holzer diagnostic Testing Center-Athens	2131 East State Street	Athens	OH	Terminated
DSH360054H	Child	DSH	HOLZER	Holzer Diagnostic Testing Center-Jackson	280 Pattonsville Road	Jackson	OH	Terminated
DSH360054J	Child	DSH	HOLZER	Holzer / Main Urology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054K	Child	DSH	HOLZER	Holzer Main / Weight Loss Center	100 Jackson Pike	Gallipolis	OH	Terminated
DSH360054L	Child	DSH	HOLZER	Holzer Main / Cardio Surgery	100 Jackson Pike	Gallipolis	OH	Terminated
DSH360054M	Child	DSH	HOLZER	Holzer Main / Plastic Surgery	100 Jackson Pike	Gallipolis	OH	Terminated
DSH360054N	Child	DSH	HOLZER	Holzer / Main ENT	100 Jackson Pike	Gallipolis	OH	Active
DSH360054P	Child	DSH	HOLZER	Holzer / Main Orthopedics	100 Jackson Pike	Gallipolis	OH	Active
DSH360054Q	Child	DSH	HOLZER	Holzer / Main Ophthalmology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054R	Child	DSH	HOLZER	Holzer / Main OB/GYN	100 Jackson Pike	Gallipolis	OH	Active
DSH360054S	Child	DSH	HOLZER	Holzer / Main Gastroenterology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054T	Child	DSH	HOLZER	Holzer Main / Dermatology	100 Jackson Pike	Gallipolis	OH	Terminated
DSH360054U	Child	DSH	HOLZER	Holzer / Main General Surgery	100 Jackson Pike	Gallipolis	OH	Active
DSH360054V	Child	DSH	HOLZER	Holzer / Main Endocrinology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054W	Child	DSH	HOLZER	Holzer Main / Urgent Care	100 Jackson Pike	Gallipolis	OH	Active
DSH360054X	Child	DSH	HOLZER	Holzer / Main Nephrology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054Y	Child	DSH	HOLZER	Holzer / Main Pulmonology	100 Jackson Pike	Gallipolis	OH	Active
DSH360054Z	Child	DSH	HOLZER	Holzer Main / Occupational Medicine	100 Jackson Pike	Gallipolis	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		4/28/2017 12:00:00 AM	11/16/2017 2:22 PM
Details	State	Update	Recertification	Active	To Be Terminated	11/16/2017 2:22 PM
Terminations	Termination Comments	Update	Recertification		Site became Non-provider based effective 5/1/2017	11/16/2017 2:22 PM
Terminations	Termination Date	Update	Recertification		1/1/2018 12:00:00 AM	11/16/2017 2:22 PM
Terminations	Termination Effective Date	Update	Recertification		5/1/2017 12:00:00 AM	11/16/2017 2:22 PM
Terminations	Termination Reason	Update	Recertification		Business decision by the Covered Entity	11/16/2017 2:22 PM
Contacts	Authorizing Official	Insert	AO Change Request		Haynes, Michael P EVP/CFO Holzer 7404465743	11/8/2017 2:28 PM
Contacts	Primary Contact	Update		Clemente, Mary Ann 340B Compliance Analyst 7404465803	Clemente, Mary Ann 340B Compliance Analyst Holzer 7404465803	9/29/2017 7:46 AM
Contacts	Primary Contact	Update		Lynch, Jennifer System Director of Pharmacy 7404465235	Clemente, Mary Ann 340B Compliance Analyst 7404465803	5/15/2017 12:45 PM
Contacts	Signed By	Insert			Meyer, Christopher Chief Medical Officer 7404465051	5/15/2017 12:45 PM
Addresses	Main Address	Insert			98 STATE ST PROCTORVILLE, OH 45669-8163	3/8/2017 2:18 PM
Details	Entity Name	Update		HOLZER MEDICAL CENTER	HOLZER	3/8/2017 2:18 PM
Contacts	Primary Contact	Insert			Lynch, Jennifer System Director of Pharmacy 7404465235	9/27/2016 12:08 PM
Details	Last Recertification Date	Update		9/4/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 2:04 PM
Details	Last Recertification Date	Update			9/4/2015 12:00:00 AM	9/4/2015 3:04 PM
Dates	Participating Approval Date	Update			3/4/2015 12:00:00 AM	3/4/2015 5:32 PM
Details	State	Update		Pending	Active	3/4/2015 5:32 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/4/2015 5:32 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_49411	DSH360054CP	2/6/2015 9:40 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_49411	1/14/2015 5:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/14/2015 5:28 PM
Medicaid Billing	Medicaid: Number	Insert			4046562	1/14/2015 5:28 PM
Medicaid Billing	Medicaid: State	Insert			OH	1/14/2015 5:28 PM
Details	Last Recertification Date	Insert				1/14/2015 5:28 PM
Details	Grant Number	Insert				1/14/2015 5:28 PM
Details	340B ID	Insert				1/14/2015 5:28 PM
Details	Is Authorizing Official EHB Data	Insert				1/14/2015 5:28 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/14/2015 5:28 PM
Details	Medicare Provider Number	Insert			360054	1/14/2015 5:28 PM
Details	Entity Name	Insert			HOLZER MEDICAL CENTER	1/14/2015 5:28 PM
Details	Program Code	Insert			DSH	1/14/2015 5:28 PM
Details	Entity Subname	Insert			HOLZER / Lawrence County Radiology	1/14/2015 5:28 PM
Dates	Participating Approval Date	Insert				1/14/2015 5:28 PM
Details	State	Insert			Pending	1/14/2015 5:28 PM
Dates	Registration Date	Insert			1/14/2015 12:00:00 AM	1/14/2015 5:28 PM
Dates	Signed By Date	Insert			1/14/2015 12:00:00 AM	1/14/2015 5:28 PM
Dates	Start Date	Insert				1/14/2015 5:28 PM
Terminations	Termination Comments	Insert				1/14/2015 5:28 PM
Terminations	Termination Date	Insert				1/14/2015 5:28 PM
Terminations	Termination Effective Date	Insert				1/14/2015 5:28 PM
Terminations	Termination Reason	Insert				1/14/2015 5:28 PM