Covered Entity Details

CAH361312-01 MERCY HEALTH - URBANA HOSPITAL (Active) - information as of 6/1/2025 4:02:59 AM

Main Details

Name

MERCY HEALTH - URBANA HOSPITAL

Subdivision Name

Wound Care Center

Type

Critical Access Hospital

Rural

340B ID

CAH361312-01

Medicare Provider Number

361312

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/5/2016

Participating Start Date

4/1/2016

Participating Approval Date

3/11/2016

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Bon Secours Mercy Health
Jenelle Dee Zelinski, CFO-Springfield Region
(937) 523-5512

Primary Contact

Mercy Health
Joshua Walker, Director of Pharmacy
(937) 523-5301

Addresses

Street Address

1430 East U.S. Highway 36
Suite B
Urbana, OH 43078

Billing Address

MERCY MEMORIAL HOSPITAL
904 Scioto Street
Urbana, OH 43078

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	5887901	1144286352

Shipping Addresses

Shipping Address 1

MERCY MEMORIAL HOSPITAL
904 Scioto Street
Urbana, OH 43078

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
CAH361312-01	Child	CAH	MERCY HEALTH - URBANA HOSPITAL	Wound Care Center	1430 East U.S. Highway 36	Urbana	OH	Active
CAH361312-02	Child	CAH	MERCY MEMORIAL HOSPITAL	Community Mercy REACH - Substance Abuse	904 Scioto Street	Urbana	OH	Terminated
CAH361312-03	Child	CAH	MERCY MEMORIAL HOSPITAL	Wound Care Center / Hyperbaric Therapy	1430 East U.S. Highway 36	Urbana	OH	Terminated
CAH361312-04	Child	CAH	MERCY MEMORIAL HOSPITAL	Excel Urbana Sports Medicine & Rehabilitation / Rehabilitation Therapy	1450 East U.S. Highway 36	Urbana	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Latham, Brian Douglas Executive Director of Pharmacy Bon Secours Mercy Health 4192357674	Walker, Joshua Director of Pharmacy Mercy Health 9375235301	1/14/2025 1:58 PM
Contacts	Primary Contact	Update	PC Change Request	Walker, Joshua Director of Pharmacy Mercy Health 9375235301	Latham, Brian Douglas Executive Director of Pharmacy Bon Secours Mercy Health 4192357674	11/18/2024 11:32 AM
Details	Last Recertification Date	Update	Recertification	8/28/2023 12:10:45 PM	8/15/2024 9:05:58 AM	8/15/2024 9:05 AM
Details	Entity Name	Update	Change Request	MERCY MEMORIAL HOSPITAL	MERCY HEALTH - URBANA HOSPITAL	7/29/2024 6:50 AM
Contacts	Primary Contact	Update	Profile Change Request	Walker, Joshua Director of Pharmacy Community Mercy Health Partners 9375235301	Walker, Joshua Director of Pharmacy Mercy Health 9375235301	11/20/2023 6:50 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 8:42:30 AM	8/28/2023 12:10:45 PM	8/28/2023 12:10 PM
Contacts	Authorizing Official	Update	Profile Change Request	Zelinski, Jenelle Dee CFO-Springfield Region Bon Secours Mercy Health 9375236634	Zelinski, Jenelle Dee CFO-Springfield Region Bon Secours Mercy Health 9375235512	8/31/2022 9:10 AM
Details	Last Recertification Date	Update	Recertification	9/2/2021 10:48:14 AM	8/31/2022 8:42:30 AM	8/31/2022 8:42 AM
Contacts	Primary Contact	Update	Group Change Request	Prince, Adrian J Pharmacy Clinical Coordinator Community Mercy Health Partners 9375235302	Walker, Joshua Director of Pharmacy Community Mercy Health Partners 9375235301	2/17/2022 7:29 AM
Contacts	Primary Contact	Update	Profile Change Request	Prince, Adrian J Director of Pharmacy Community Mercy Health Partners 9375235302	Prince, Adrian J Pharmacy Clinical Coordinator Community Mercy Health Partners 9375235302	2/16/2022 3:10 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 5:47:37 PM	9/2/2021 10:48:14 AM	9/2/2021 10:48 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1144286352	9/8/2020 5:47 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/8/2020 5:47 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1144286352 ( )		9/8/2020 5:47 PM
Details	Last Recertification Date	Update	Recertification	8/30/2019 9:20:12 AM	9/8/2020 5:47:37 PM	9/8/2020 5:47 PM
Details	Last Recertification Date	Update	Recertification	8/27/2018 1:50:17 PM	8/30/2019 9:20:12 AM	8/30/2019 9:20 AM
Contacts	Authorizing Official	Update	Change Request	Kusnierz, William Joseph Market CFO Community Mercy Health Partners 9375235512	Zelinski, Jenelle Dee CFO-Springfield Region Bon Secours Mercy Health 9375236634	6/7/2019 10:39 AM
Addresses	Shipping Address	Insert	Change Request		MERCY MEMORIAL HOSPITAL 904 Scioto Street Urbana, OH 43078	3/25/2019 2:58 PM
Addresses	Billing Address	Insert	Change Request		MERCY MEMORIAL HOSPITAL 904 Scioto Street Urbana, OH 43078	9/27/2018 4:21 PM
Addresses	Main Address	Update	Change Request	904 Scioto Street Urbana, OH 43078	1430 East U.S. Highway 36 Suite B Urbana, OH 43078	9/27/2018 4:21 PM
Addresses	Main Address	Update	Change Request	1430 East US Highway 36, Suite B Urbana, OH 43078	904 Scioto Street Urbana, OH 43078	9/17/2018 3:15 PM
Contacts	Primary Contact	Update	Profile Change Request	Prince, Adrian J Interim Pharmacy Director Community Mercy Health Partners 9375235302	Prince, Adrian J Director of Pharmacy Community Mercy Health Partners 9375235302	8/30/2018 10:52 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 2:23:21 PM	8/27/2018 1:50:17 PM	8/27/2018 1:50 PM
Contacts	Primary Contact	Update		Prince, Adrian Interim Pharmacy Director Community Mercy Health Partners 9375235302	Prince, Adrian J Interim Pharmacy Director Community Mercy Health Partners 9375235302	1/29/2018 10:41 AM
Contacts	Primary Contact	Update	Change Request	Allen, Pam Director of Pharmacy Springfield Regional Medical Center 9375235301	Prince, Adrian Interim Pharmacy Director Community Mercy Health Partners 9375235302	1/25/2018 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	01541010 (KY)		12/12/2017 12:46 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100039220 (IN)		12/12/2017 12:46 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/15/2017 2:23:21 PM	11/15/2017 2:23 PM
Contacts	Authorizing Official	Update		Kusnierz, William Market CFO 9375235512	Kusnierz, William Joseph Market CFO Community Mercy Health Partners 9375235512	10/19/2017 1:20 PM
Contacts	Primary Contact	Update		Allen, Pam Director of Pharmacy 9375235301	Allen, Pam Director of Pharmacy Springfield Regional Medical Center 9375235301	10/18/2017 4:08 PM
Contacts	Primary Contact	Insert			Allen, Pam Director of Pharmacy 9375235301	6/26/2017 6:35 AM
Contacts	Signed By	Insert			Lupton, Todd CFO, South Markets 5139814840	6/26/2017 6:35 AM
Contacts	Authorizing Official	Insert			Kusnierz, William Market CFO 9375235512	6/26/2017 6:35 AM
Addresses	Main Address	Insert			1430 East US Highway 36, Suite B Urbana, OH 43078	6/26/2017 6:33 AM
Details	Last Recertification Date	Update			8/30/2016 12:00:00 AM	8/30/2016 2:23 PM
Medicaid Billing	NPI: Number	Update		1568562551	1144286352	3/21/2016 5:08 PM
Dates	Participating Approval Date	Update			3/11/2016 12:00:00 AM	3/11/2016 4:10 PM
Details	State	Update		Pending	Active	3/11/2016 4:10 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	3/11/2016 4:10 PM
Details	Entity Subname	Update		Wound Care Center / Wound Care	Wound Care Center	2/4/2016 2:56 PM
Details	Entity Subname	Update		Wound Care Center - Wound Care	Wound Care Center / Wound Care	1/6/2016 3:31 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_56563	CAH361312-01	1/6/2016 3:26 PM
Details	Entity Subname	Update		Mercy Memorial Wound Care Center - Wound Care	Wound Care Center - Wound Care	1/6/2016 3:26 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_56563	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: Number	Insert			5887901	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: State	Insert			OH	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: Number	Insert			01541010	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: State	Insert			KY	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: Number	Insert			100039220	1/5/2016 1:12 PM
Medicaid Billing	Medicaid: State	Insert			IN	1/5/2016 1:12 PM
Medicaid Billing	NPI: Number	Insert			1568562551	1/5/2016 1:12 PM
Details	Last Recertification Date	Insert				1/5/2016 1:12 PM
Details	Grant Number	Insert				1/5/2016 1:12 PM
Details	340B ID	Insert				1/5/2016 1:12 PM
Details	Is Authorizing Official EHB Data	Insert				1/5/2016 1:12 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/5/2016 1:12 PM
Details	Medicare Provider Number	Insert			361312	1/5/2016 1:12 PM
Details	Entity Name	Insert			MERCY MEMORIAL HOSPITAL	1/5/2016 1:12 PM
Details	Program Code	Insert			CAH	1/5/2016 1:12 PM
Details	Entity Subname	Insert			Mercy Memorial Wound Care Center - Wound Care	1/5/2016 1:12 PM
Dates	Participating Approval Date	Insert				1/5/2016 1:12 PM
Details	State	Insert			Pending	1/5/2016 1:12 PM
Dates	Registration Date	Insert			1/5/2016 12:00:00 AM	1/5/2016 1:12 PM
Dates	Signed By Date	Insert			1/5/2016 12:00:00 AM	1/5/2016 1:12 PM
Dates	Start Date	Insert				1/5/2016 1:12 PM
Terminations	Termination Comments	Insert				1/5/2016 1:12 PM
Terminations	Termination Date	Insert				1/5/2016 1:12 PM
Terminations	Termination Effective Date	Insert				1/5/2016 1:12 PM
Terminations	Termination Reason	Insert				1/5/2016 1:12 PM