Covered Entity Details

RRC180102-17 MERCY HEALTH LOURDES HOSPITAL LLC (Terminated) - information as of 5/4/2025 10:21:25 PM

Main Details

Name

MERCY HEALTH LOURDES HOSPITAL LLC

Subdivision Name

Cardiology & Vascular Testing / LMP Vascular Lab

Type

Rural Referral Center

Rural

Yes

340B ID

RRC180102-17

Medicare Provider Number

180102

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

11/17/2016

Participating Start Date

1/1/2017

Participating Approval Date

12/8/2016

Last Recertification Date

8/30/2019

Termination Date
Termination Reason

10/1/2020
Change of covered entity type

Contacts

Authorizing Official

Lourdes Hospital
Alan Archbold, Chief Financial Officer Kentucky Region
(270) 444-2553

Primary Contact

Mercy Health - Lourdes Hospital
Alisa Fish, Director of Pharmacy
(270) 444-2774

Addresses

Street Address

225 MEDICAL CENTER DRIVE
STE. 401
Paducah, KY 42003

Billing Address

Mercy Health Lourdes Hospital LLC
1530 Lone Oak Road
Paducah, KY 42003

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
KY	01012152
		1346244126

Shipping Addresses

Shipping Address 1

Mercy Health Lourdes Hospital LLC
1530 Lone Oak Road
Paducah, KY 42003

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
RRC180102-01	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LOURDES BEHAVIORAL HLTH OUTPATIENT	1532 LONE OAK RD., STE. 345	PADUCAH	KY	Terminated
RRC180102-02	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	CARDIOLOGY AND VASCULAR TESTING	225 MEDICAL CENTER DRIVE	PADUCAH	KY	Terminated
RRC180102-03	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LOURDES CENTER FOR SLEEP DISORDERS	3125 PARISA DR	PADUCAH	KY	Terminated
RRC180102-04	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	OUTPATIENT INFUSION THERAPY	1532 LONE OAK RD.	PADUCAH	KY	Terminated
RRC180102-05	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LOURDES-MURRAY PAIN MANAGEMENT CTR	1710 HWY 121 N. BYPASS, SUITE I	MURRAY	KY	Terminated
RRC180102-06	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LOURDES WOUND CARE - BENTON	83 WELLNESS WAY, SUITE 5	BENTON	KY	Terminated
RRC180102-07	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LOURDES WOUND CARE	225 MEDICAL CENTER DRIVE	PADUCAH	KY	Terminated
RRC180102-08	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LOURDES IMAGING-FAMILY HEALTH PARTNERS	548 LONE OAK RD	PADUCAH	KY	Terminated
RRC180102-09	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	Lourdes Imaging - Benton	83 Wellness Way	Benton	KY	Terminated
RRC180102-10	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	OUTPATIENT RADIOLOGY	1532 LONE OAK RD	PADUCAH	KY	Terminated
RRC180102-11	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LOURDES WOMEN'S CENTER	1532 LONE OAK ROAD	PADUCAH	KY	Terminated
RRC180102-12	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LMP- WOMEN'S IMAGING CENTER-RADIOLOGY-DIAGNOSTIC	225 MEDICAL CENTER DR	PADUCAH	KY	Terminated
RRC180102-13	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	PADUCAH DIAGNOSTIC CENTER / LMP Radiology	225 MEDICAL CENTER DRIVE	PADUCAH	KY	Terminated
RRC180102-14	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	PADUCAH DIAGNOSTIC CENTER / CT Scan	225 MEDICAL CENTER DRIVE	PADUCAH	KY	Terminated
RRC180102-15	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	PADUCAH DIAGNOSTIC CENTER / Nuclear Medicine	225 MEDICAL CENTER DRIVE	PADUCAH	KY	Terminated
RRC180102-16	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	LMP- WOMEN'S IMAGING CENTER / LMP Ultrasound	225 MEDICAL CENTER DR	PADUCAH	KY	Terminated
RRC180102-17	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	Cardiology & Vascular Testing / LMP Vascular Lab	225 MEDICAL CENTER DRIVE	Paducah	KY	Terminated
RRC180102-18	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	Lourdes Pain Management - Pain Management	1532 Lone Oak Road	Paducah	KY	Terminated
RRC180102-19	Child	RRC	MERCY HEALTH LOURDES HOSPITAL LLC	Mercy Health Physical and Pain Medicine - Pain Management	1532 Lone Oak Road	Paducah	KY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	8/28/2020 9:01 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	8/28/2020 9:01 AM
Terminations	Termination Date	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	8/28/2020 9:01 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		10/1/2020 12:00:00 AM	8/28/2020 9:01 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	8/28/2020 9:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/10/2020 3:06 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01012152	3/10/2020 3:06 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	3/10/2020 3:06 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346244126	3/10/2020 3:06 PM
Contacts	Primary Contact	Update	Change Request	Branch, Keithen Director of Pharmacy Mercy Health Lourdes Hospital LLC 2704442774	Fish, Alisa Director of Pharmacy Mercy Health - Lourdes Hospital 2704442774	1/31/2020 6:57 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 2:25:13 PM	8/30/2019 4:03:09 PM	8/30/2019 4:03 PM
Addresses	Shipping Address	Insert	Change Request		Mercy Health Lourdes Hospital LLC 1530 Lone Oak Road Paducah, KY 42003	2/4/2019 9:50 AM
Addresses	Billing Address	Insert	Change Request		Mercy Health Lourdes Hospital LLC 1530 Lone Oak Road Paducah, KY 42003	9/26/2018 3:05 PM
Details	Last Recertification Date	Update	Recertification	11/6/2017 8:56:15 AM	8/16/2018 2:25:13 PM	8/16/2018 2:25 PM
Details	Last Recertification Date	Update	Recertification	10/26/2017 9:06:10 AM	11/6/2017 8:56:15 AM	11/6/2017 8:56 AM
Details	Last Recertification Date	Update	Recertification		10/26/2017 9:06:10 AM	10/26/2017 9:06 AM
Contacts	Authorizing Official	Update		Archbold, Alan Chief Financial Officer Kentucky Region 2704442553	Archbold, Alan Chief Financial Officer Kentucky Region Lourdes Hospital 2704442553	9/28/2017 5:55 PM
Contacts	Signed By	Update		Archbold, Alan Chief Financial Officer Kentucky Region 2704442553	Archbold, Alan Chief Financial Officer Kentucky Region Lourdes Hospital 2704442553	9/28/2017 5:55 PM
Contacts	Primary Contact	Update		Branch, Keithen Director of Pharmacy 2704442774	Branch, Keithen Director of Pharmacy Mercy Health Lourdes Hospital LLC 2704442774	9/25/2017 4:10 PM
Contacts	Authorizing Official	Insert			Archbold, Alan Chief Financial Officer Kentucky Region 2704442553	8/4/2017 11:42 AM
Contacts	Signed By	Insert			Archbold, Alan Chief Financial Officer Kentucky Region 2704442553	8/4/2017 11:42 AM
Contacts	Primary Contact	Insert			Branch, Keithen Director of Pharmacy 2704442774	8/4/2017 11:42 AM
Addresses	Main Address	Insert			225 MEDICAL CENTER DRIVE STE. 401 Paducah, KY 42003	12/8/2016 1:34 PM
Dates	Participating Approval Date	Update			12/8/2016 12:00:00 AM	12/8/2016 1:34 PM
Details	State	Update		Pending	Active	12/8/2016 1:34 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	12/8/2016 1:34 PM
Details	340B ID	Update		RRC180102-18	RRC180102-17	12/5/2016 8:55 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_73617	RRC180102-18	11/21/2016 10:44 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_73617	11/17/2016 4:55 PM
Details	Last Recertification Date	Insert				11/17/2016 4:55 PM
Details	Grant Number	Insert				11/17/2016 4:55 PM
Details	340B ID	Insert				11/17/2016 4:55 PM
Details	Is Authorizing Official EHB Data	Insert				11/17/2016 4:55 PM
Dates	Last Date That 340B Drugs Purchased	Insert				11/17/2016 4:55 PM
Details	Medicare Provider Number	Insert			180102	11/17/2016 4:55 PM
Details	Entity Name	Insert			MERCY HEALTH LOURDES HOSPITAL LLC	11/17/2016 4:55 PM
Details	Program Code	Insert			RRC	11/17/2016 4:55 PM
Details	Entity Subname	Insert			Cardiology & Vascular Testing / LMP Vascular Lab	11/17/2016 4:55 PM
Dates	Participating Approval Date	Insert				11/17/2016 4:55 PM
Details	State	Insert			Pending	11/17/2016 4:55 PM
Dates	Registration Date	Insert			11/17/2016 12:00:00 AM	11/17/2016 4:55 PM
Dates	Signed By Date	Insert			11/17/2016 12:00:00 AM	11/17/2016 4:55 PM
Dates	Start Date	Insert				11/17/2016 4:55 PM
Terminations	Termination Comments	Insert				11/17/2016 4:55 PM
Terminations	Termination Date	Insert				11/17/2016 4:55 PM
Terminations	Termination Effective Date	Insert				11/17/2016 4:55 PM
Terminations	Termination Reason	Insert				11/17/2016 4:55 PM