Covered Entity Details

DSH360025A FIRELANDS REGIONAL MEDICAL CENTER (Terminated) - information as of 5/29/2025 2:00:55 AM

Main Details

Name

FIRELANDS REGIONAL MEDICAL CENTER

Subdivision Name

Infusion Services

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH360025A

Medicare Provider Number

360025

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/10/2016

Participating Start Date

1/1/2017

Participating Approval Date

11/1/2016

Last Recertification Date

11/3/2017

Termination Date
Termination Reason

10/1/2018
Site closure

Contacts

Authorizing Official

Firelands Regional Medical Center
Daniel J. Moncher, Executive Vice President & CFO
(419) 557-7793

Primary Contact

Firelands Regional Medical Center
David Waller, Director, Pharmacy Services
(419) 557-6942

Addresses

Street Address

1401 Bone Creek Drive
Sandusky, OH 44870

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	3293725
		1801884655

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
DSH360025A	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Infusion Services	1401 Bone Creek Drive	Sandusky	OH	Terminated
DSH360025B	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Cancer Center	701 Tyler Street	Sandusky	OH	Active
DSH360025C	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling and Recovery Services	22052 West State Route 51	Genoa	OH	Terminated
DSH360025D	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling & Recovery Services	76 ASHWOOD DR	TIFFIN	OH	Active
DSH360025E	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	FIRELANDS REGIONAL SURGERY CENTER	2800 HAYES AVE E	SANDUSKY	OH	Terminated
DSH360025F	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Center for Coordinated Care	1221 Hayes Avenue	Sandusky	OH	Active
DSH360025G	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Bellevue Dialysis - outpatient	290 Progress Drive	Bellevue	OH	Active
DSH360025H	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	FIRELANDS COUNSELING AND REVOVERY SERVICES	76 ASHWOOD DR	TIFFIN	OH	Terminated
DSH360025J	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Pierce Street Dialysis	904 Pierce Street	Sandusky	OH	Active
DSH360025K	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	FIRELANDS COUNSELING AND RECOVERY SERVICES	6150 Park Square Drive	Lorain	OH	Terminated
DSH360025L	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling and Recovery Services	335 Buckeye Blvd	Port Clinton	OH	Active
DSH360025M	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	FIRELANDS COUNSELING AND RECOVERY SERVICES	292 BENEDICT AVE	NORWALK	OH	Active
DSH360025N	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling and Recovery Services	97 Houpt Drive, Suite W	Upper Sandusky	OH	Terminated
DSH360025P	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling and Recovery Services	1925 HAYES AVE	SANDUSKY	OH	Active
DSH360025Q	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling and Recovery Services	1100 Neal Zick Road	Willard	OH	Terminated
DSH360025R	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling & Recovery Services	675 BARTSON RD	FREMONT	OH	Active
DSH360025S	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling & Recovery Services	122W CENTER ST	FOSTORIA	OH	Terminated
DSH360025T	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Firelands Counseling and Recovery Services	290 Progress Drive, Suite B	Bellevue	OH	Active
DSH360025U	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Imaging Services	2500 WEST STRUB ROAD	SANDUSKY	OH	Terminated
DSH360025V	Child	DSH	FIRELANDS REGIONAL MEDICAL CENTER	Infusion Center - Varied Specialties	701 Tyler Street	Sandusky	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2018 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/1/2017 12:00:00 AM	7/6/2018 8:53 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/6/2018 8:53 AM
Terminations	Termination Date	Update	Termination Request		10/1/2018 12:00:00 AM	7/6/2018 8:53 AM
Terminations	Termination Effective Date	Update	Termination Request		7/1/2017 12:00:00 AM	7/6/2018 8:53 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	7/6/2018 8:53 AM
Contacts	Primary Contact	Insert	Recertification		Waller, David Director, Pharmacy Services Firelands Regional Medical Center 4195576942	11/3/2017 10:11 AM
Details	Last Recertification Date	Update	Recertification		11/3/2017 10:11:26 AM	11/3/2017 10:11 AM
Contacts	Authorizing Official	Update		Moncher, Daniel J. Executive Vice President & CFO 4195577793	Moncher, Daniel J. Executive Vice President & CFO Firelands Regional Medical Center 4195577793	9/19/2017 10:30 AM
Contacts	Signed By	Update		Moncher, Daniel J. Executive Vice President & CFO 4195577793	Moncher, Daniel J. Executive Vice President & CFO Firelands Regional Medical Center 4195577793	9/19/2017 10:30 AM
Contacts	Authorizing Official	Insert			Moncher, Daniel J. Executive Vice President & CFO 4195577793	3/23/2017 7:53 AM
Contacts	Signed By	Insert			Moncher, Daniel J. Executive Vice President & CFO 4195577793	3/23/2017 7:53 AM
Addresses	Main Address	Insert			1401 Bone Creek Drive Sandusky, OH 44870	11/1/2016 11:01 AM
Dates	Participating Approval Date	Update			11/1/2016 12:00:00 AM	11/1/2016 10:52 AM
Details	State	Update		Pending	Active	11/1/2016 10:52 AM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	11/1/2016 10:52 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_72734	DSH360025A	10/18/2016 1:00 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_72734	10/10/2016 10:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/10/2016 10:30 AM
Medicaid Billing	Medicaid: Number	Insert			3293725	10/10/2016 10:30 AM
Medicaid Billing	Medicaid: State	Insert			OH	10/10/2016 10:30 AM
Medicaid Billing	NPI: Number	Insert			1801884655	10/10/2016 10:30 AM
Details	Last Recertification Date	Insert				10/10/2016 10:30 AM
Details	Grant Number	Insert				10/10/2016 10:30 AM
Details	340B ID	Insert				10/10/2016 10:30 AM
Details	Is Authorizing Official EHB Data	Insert				10/10/2016 10:30 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/10/2016 10:30 AM
Details	Medicare Provider Number	Insert			360025	10/10/2016 10:30 AM
Details	Entity Name	Insert			FIRELANDS REGIONAL MEDICAL CENTER	10/10/2016 10:30 AM
Details	Program Code	Insert			DSH	10/10/2016 10:30 AM
Details	Entity Subname	Insert			Infusion Services	10/10/2016 10:30 AM
Dates	Participating Approval Date	Insert				10/10/2016 10:30 AM
Details	State	Insert			Pending	10/10/2016 10:30 AM
Dates	Registration Date	Insert			10/10/2016 12:00:00 AM	10/10/2016 10:30 AM
Dates	Signed By Date	Insert			10/10/2016 12:00:00 AM	10/10/2016 10:30 AM
Dates	Start Date	Insert				10/10/2016 10:30 AM
Terminations	Termination Comments	Insert				10/10/2016 10:30 AM
Terminations	Termination Date	Insert				10/10/2016 10:30 AM
Terminations	Termination Effective Date	Insert				10/10/2016 10:30 AM
Terminations	Termination Reason	Insert				10/10/2016 10:30 AM