Covered Entity Details

CAH361331-04 Adena Fayette Medical Center (Active) - information as of 5/15/2025 11:53:58 PM

Main Details

Name

Adena Fayette Medical Center

Subdivision Name

Adena Fayette Rural Health Clinic - OB/GYN

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH361331-04

Medicare Provider Number

361331

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/16/2017

Participating Start Date

1/1/2018

Participating Approval Date

10/18/2017

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Adena Health System
Katherine Edrington, Chief Operations Officer
(740) 779-7282

Primary Contact

Adena Health System
Fred Yingling, Director of Pharmacy
(740) 779-7648

Addresses

Street Address

1510 Columbus Avenue
MAB2 Suite 230
Washington Court House, OH 43160

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	2970665	1013220805

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
CAH361331-01	Child	CAH	FAYETTE COUNTY MEMORIAL HOSPITAL	Fayette Rural Health Clinic 1	1450 Columbus Ave.	Washington Court House	OH	Terminated
CAH361331-02	Child	CAH	Adena Fayette Medical Center	Fayette Rural Health Clinic 2	1510 Columbus Ave.	Washington Court House	OH	Active
CAH361331-04	Child	CAH	Adena Fayette Medical Center	Adena Fayette Rural Health Clinic - OB/GYN	1510 Columbus Avenue	Washington Court House	OH	Active
CAH361331-05	Child	CAH	Adena Fayette Medical Center	Fayette Cancer Care - Oncology	1510 Columbus Avenue	Washington Court House	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/11/2023 10:15:06 AM	8/20/2024 3:01:09 PM	8/20/2024 3:01 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 4:28:27 PM	9/11/2023 10:15:06 AM	9/11/2023 10:15 AM
Details	Entity Subname	Update	Recertification	Fayette Rural Health Clinic - Women's Center	Adena Fayette Rural Health Clinic - OB/GYN	9/11/2023 10:15 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 12:08:00 PM	8/31/2022 4:28:27 PM	8/31/2022 4:28 PM
Contacts	Authorizing Official	Update	Change Request	Carlson, Lisa Marie CFO Adena Health System 7407797582	Edrington, Katherine Chief Operations Officer Adena Health System 7407797282	4/8/2022 12:36 PM
Contacts	Primary Contact	Update	Change Request	Camp, William Zacharie Director of Pharmacy Comprehensive Pharmacy Services 7406060376	Yingling, Fred Director of Pharmacy Adena Health System 7407797648	9/10/2021 4:00 PM
Details	Last Recertification Date	Update	Recertification	8/17/2020 10:27:36 AM	8/27/2021 12:08:00 PM	8/27/2021 12:08 PM
Contacts	Authorizing Official	Update	Change Request	Lemle, Trent CFO Fayette County Memorial Hospital 7403332798	Carlson, Lisa Marie CFO Adena Health System 7407797582	5/27/2021 10:21 AM
Details	Entity Name	Update	Change Request	FAYETTE COUNTY MEMORIAL HOSPITAL	Adena Fayette Medical Center	5/27/2021 10:21 AM
Contacts	Primary Contact	Update	Profile Change Request	Camp, William Zacharie Pharmacy Leader Fayette County Memorial Address 7403332901	Camp, William Zacharie Director of Pharmacy Comprehensive Pharmacy Services 7406060376	5/18/2021 12:01 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1013220805	8/17/2020 10:27 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	8/17/2020 10:27 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1013220805 ( )		8/17/2020 10:27 AM
Details	Last Recertification Date	Update	Recertification	9/5/2019 7:36:30 AM	8/17/2020 10:27:36 AM	8/17/2020 10:27 AM
Contacts	Primary Contact	Update	Recertification	Rowe, Laura Director of Pharmacy Fayette County Memorial Hospital 7403332901	Camp, William Zacharie Pharmacy Leader Fayette County Memorial Address 7403332901	9/5/2019 7:36 AM
Details	Last Recertification Date	Update	Recertification	9/11/2018 7:30:47 AM	9/5/2019 7:36:30 AM	9/5/2019 7:36 AM
Details	Last Recertification Date	Update	Recertification		9/11/2018 7:30:47 AM	9/11/2018 7:30 AM
Details	340B ID	Update	OPA Edit	CAH361331 -04	CAH361331-04	12/29/2017 4:52 PM
Details	State	Update	OPA Edit	Approved	Active	12/29/2017 4:52 PM
Contacts	Signed By	Insert	New Registration		Lemle, Trent CFO Fayette County Memorial Hospital 7403332798	10/18/2017 1:53 PM
Details	340B ID	Update	New Registration		CAH361331 -04	10/18/2017 1:53 PM
Details	Entity Subname	Update	New Registration	Fayette Rural Health Clinic	Fayette Rural Health Clinic - Women's Center	10/18/2017 1:53 PM
Dates	Participating Approval Date	Update	New Registration		10/18/2017 1:53:15 PM	10/18/2017 1:53 PM
Details	State	Update	New Registration	Pending	Approved	10/18/2017 1:53 PM
Dates	Signed By Date	Update	New Registration		10/16/2017 4:28:32 PM	10/18/2017 1:53 PM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	10/18/2017 1:53 PM
Addresses	Main Address	Insert	New Registration		1510 Columbus Avenue MAB2 Suite 230 Washington Court House, OH 43160	10/16/2017 4:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/16/2017 4:28 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		2970665	10/16/2017 4:28 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	10/16/2017 4:28 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1013220805	10/16/2017 4:28 PM
Contacts	Primary Contact	Insert	New Registration		Rowe, Laura Director of Pharmacy Fayette County Memorial Hospital 7403332901	10/16/2017 4:28 PM
Contacts	Authorizing Official	Insert	New Registration		Lemle, Trent CFO Fayette County Memorial Hospital 7403332798	10/16/2017 4:28 PM
Details	Last Recertification Date	Insert	New Registration			10/16/2017 4:28 PM
Details	Grant Number	Insert	New Registration			10/16/2017 4:28 PM
Details	340B ID	Insert	New Registration			10/16/2017 4:28 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/16/2017 4:28 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/16/2017 4:28 PM
Details	Medicare Provider Number	Insert	New Registration		361331	10/16/2017 4:28 PM
Details	Entity Name	Insert	New Registration		FAYETTE COUNTY MEMORIAL HOSPITAL	10/16/2017 4:28 PM
Details	Program Code	Insert	New Registration		CAH	10/16/2017 4:28 PM
Details	Entity Subname	Insert	New Registration		Fayette Rural Health Clinic	10/16/2017 4:28 PM
Dates	Participating Approval Date	Insert	New Registration			10/16/2017 4:28 PM
Details	State	Insert	New Registration		Pending	10/16/2017 4:28 PM
Dates	Registration Date	Insert	New Registration		10/16/2017 4:28:29 PM	10/16/2017 4:28 PM
Dates	Signed By Date	Insert	New Registration			10/16/2017 4:28 PM
Dates	Start Date	Insert	New Registration			10/16/2017 4:28 PM
Terminations	Termination Comments	Insert	New Registration			10/16/2017 4:28 PM
Terminations	Termination Date	Insert	New Registration			10/16/2017 4:28 PM
Terminations	Termination Effective Date	Insert	New Registration			10/16/2017 4:28 PM
Terminations	Termination Reason	Insert	New Registration			10/16/2017 4:28 PM