Covered Entity Details

CAH361306-01 MERCY ALLEN HOSPITAL (Terminated) - information as of 6/9/2025 12:02:29 AM

Main Details

Name

MERCY ALLEN HOSPITAL

Subdivision Name

MERCY ALLEN RURAL HEALTH CLINIC WEL - Rural Health Clinic- Wellington

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH361306-01

Medicare Provider Number

361306

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/10/2017

Participating Start Date

1/1/2018

Participating Approval Date

10/18/2017

Last Recertification Date

8/23/2024

Termination Date
Termination Reason

10/1/2024
Business decision by the Covered Entity

Contacts

Authorizing Official

MercyHealth
Cynthia Dennison, Hospital CFO Lorain
(440) 960-3640

Primary Contact

Mercy Health
Jeffrey Cook, Director of Pharmacy - Mercy Health Lorain and Allen
(440) 960-3144

Addresses

Street Address

840 Patriot Dr
WELLINGTON, OH 44090-1300

Billing Address

Mercy Allen Hospital
200 W. Lorain St.
Oberlin, OH 44074

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	0117402	1801825997

Shipping Addresses

Shipping Address 1

Mercy Allen Hospital
200 W. Lorain St.
Oberlin, OH 44074

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
CAH361306-01	Child	CAH	MERCY ALLEN HOSPITAL	MERCY ALLEN RURAL HEALTH CLINIC WEL - Rural Health Clinic- Wellington	840 Patriot Dr	WELLINGTON	OH	Terminated
CAH361306-02	Child	CAH	MERCY ALLEN HOSPITAL	MERCY ALLEN RURAL HEALTH CLINIC - Rural Health Clinic- LaGrange	105 OPPORTUNITY WAY	LAGRANGE	OH	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/6/2024 12:00:00 AM	9/6/2024 10:57 AM
Details	State	Update	Termination Request	Active	To Be Terminated	9/6/2024 10:57 AM
Terminations	Termination Date	Update	Termination Request		10/1/2024 12:00:00 AM	9/6/2024 10:57 AM
Terminations	Termination Effective Date	Update	Termination Request		9/6/2024 12:00:00 AM	9/6/2024 10:57 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	9/6/2024 10:57 AM
Details	Last Recertification Date	Update	Recertification	8/22/2023 10:12:18 AM	8/23/2024 10:14:58 AM	8/23/2024 10:14 AM
Contacts	Primary Contact	Update	Group Change Request	Baluh, Kyle 340B Program Manager Bon Secours Mercy Health 4402272762	Cook, Jeffrey Director of Pharmacy - Mercy Health Lorain and Allen Mercy Health 4409603144	7/22/2024 6:50 AM
Contacts	Primary Contact	Update	PC Change Request	Harold, Joshua Andrew Director of Pharmacy Mercy Health 3304294891	Baluh, Kyle 340B Program Manager Bon Secours Mercy Health 4402272762	6/4/2024 9:54 AM
Contacts	Authorizing Official	Update	Profile Change Request	Dennison, Cynthia Region CFO Lorain MercyHealth 4409603640	Dennison, Cynthia Hospital CFO Lorain MercyHealth 4409603640	8/22/2023 10:37 AM
Contacts	Signed By	Update	Profile Change Request	Dennison, Cynthia Region CFO Lorain MercyHealth 4409603640	Dennison, Cynthia Hospital CFO Lorain MercyHealth 4409603640	8/22/2023 10:37 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 10:40:56 AM	8/22/2023 10:12:18 AM	8/22/2023 10:12 AM
Contacts	Primary Contact	Update	PC Change Request	Suffel, Sarah Pharmacy Director MercyHealth 4409603144	Harold, Joshua Andrew Director of Pharmacy Mercy Health 3304294891	3/21/2023 10:26 AM
Details	Last Recertification Date	Update	Recertification	9/1/2021 2:21:16 PM	9/1/2022 10:40:56 AM	9/1/2022 10:40 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 3:34:14 PM	9/1/2021 2:21:16 PM	9/1/2021 2:21 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1801825997	9/2/2020 3:34 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/2/2020 3:34 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1801825997 ( )		9/2/2020 3:34 PM
Details	Last Recertification Date	Update	Recertification	9/4/2019 2:21:27 PM	9/2/2020 3:34:14 PM	9/2/2020 3:34 PM
Details	Last Recertification Date	Update	Recertification	8/27/2018 5:32:55 PM	9/4/2019 2:21:27 PM	9/4/2019 2:21 PM
Addresses	Shipping Address	Insert	Change Request		Mercy Allen Hospital 200 W. Lorain St. Oberlin, OH 44074	3/27/2019 6:48 AM
Addresses	Main Address	Update	Change Request	508 DICKSON STREET SUITE 2 WELLINGTON, OH 44090-1300	840 Patriot Dr WELLINGTON, OH 44090-1300	9/19/2018 2:05 PM
Addresses	Billing Address	Insert	Change Request		Mercy Allen Hospital 200 W. Lorain St. Oberlin, OH 44074	9/19/2018 2:05 PM
Details	Last Recertification Date	Update	Recertification		8/27/2018 5:32:55 PM	8/27/2018 5:32 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Dennison, Cynthia Region CFO Lorain MercyHealth 4409603640	10/18/2017 1:52 PM
Details	340B ID	Update	New Registration		CAH361306-01	10/18/2017 1:52 PM
Details	Entity Subname	Update	New Registration	MERCY ALLEN RURAL HEALTH CLINIC WEL	MERCY ALLEN RURAL HEALTH CLINIC WEL - Rural Health Clinic- Wellington	10/18/2017 1:52 PM
Dates	Participating Approval Date	Update	New Registration		10/18/2017 1:52:18 PM	10/18/2017 1:52 PM
Details	State	Update	New Registration	Pending	Approved	10/18/2017 1:52 PM
Dates	Signed By Date	Update	New Registration		10/11/2017 9:26:44 AM	10/18/2017 1:52 PM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	10/18/2017 1:52 PM
Addresses	Main Address	Insert	New Registration		508 DICKSON STREET SUITE 2 WELLINGTON, OH 44090-1300	10/10/2017 8:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/10/2017 8:53 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0117402	10/10/2017 8:53 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/10/2017 8:53 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1801825997	10/10/2017 8:53 AM
Contacts	Primary Contact	Insert	New Registration		Suffel, Sarah Pharmacy Director MercyHealth 4409603144	10/10/2017 8:53 AM
Contacts	Authorizing Official	Insert	New Registration		Dennison, Cynthia Region CFO Lorain MercyHealth 4409603640	10/10/2017 8:53 AM
Details	Last Recertification Date	Insert	New Registration			10/10/2017 8:53 AM
Details	Grant Number	Insert	New Registration			10/10/2017 8:53 AM
Details	340B ID	Insert	New Registration			10/10/2017 8:53 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/10/2017 8:53 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/10/2017 8:53 AM
Details	Medicare Provider Number	Insert	New Registration		361306	10/10/2017 8:53 AM
Details	Entity Name	Insert	New Registration		MERCY ALLEN HOSPITAL	10/10/2017 8:53 AM
Details	Program Code	Insert	New Registration		CAH	10/10/2017 8:53 AM
Details	Entity Subname	Insert	New Registration		MERCY ALLEN RURAL HEALTH CLINIC WEL	10/10/2017 8:53 AM
Dates	Participating Approval Date	Insert	New Registration			10/10/2017 8:53 AM
Details	State	Insert	New Registration		Pending	10/10/2017 8:53 AM
Dates	Registration Date	Insert	New Registration		10/10/2017 8:53:19 AM	10/10/2017 8:53 AM
Dates	Signed By Date	Insert	New Registration			10/10/2017 8:53 AM
Dates	Start Date	Insert	New Registration			10/10/2017 8:53 AM
Terminations	Termination Comments	Insert	New Registration			10/10/2017 8:53 AM
Terminations	Termination Date	Insert	New Registration			10/10/2017 8:53 AM
Terminations	Termination Effective Date	Insert	New Registration			10/10/2017 8:53 AM
Terminations	Termination Reason	Insert	New Registration			10/10/2017 8:53 AM