Covered Entity Details

DSH360236N CLERMONT MERCY HOSPITAL (Terminated) - information as of 5/2/2025 10:35:19 PM

Main Details

Name

CLERMONT MERCY HOSPITAL

Subdivision Name

SPECIALIZED SERVICES UNIT - AMBULATORY CARE

Type

Disproportionate Share Hospital

Rural

340B ID

DSH360236N

Medicare Provider Number

360236

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/5/2018

Participating Start Date

7/1/2018

Participating Approval Date

5/2/2018

Last Recertification Date

8/30/2021

Termination Date
Termination Reason

4/1/2022
Other

Contacts

Authorizing Official

Bon Secours Mercy Health
Emily Wagner, CFO, Mercy Health - Tiffin & Willard
(419) 455-7053

Primary Contact

Mercy Clermont Hospital
Tab Dehner, Director of Pharmacy
(513) 732-8670

Addresses

Street Address

3000 Hospital Drive
Batavia, OH 45103

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	0217447	1568562551

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
Contract Detail	HARNESS HEALTH PHARMACY	7160 INDUSTRIAL ROW DR	SUITE 330	MASON	OH	45040	05/02/2018	07/01/2018		04/01/2022	04/01/2022

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH360236A	Child	DSH	CLERMONT MERCY HOSPITAL	MH-MT. ORAB MEDICAL CENTER	154 Health Partners Cir	Mt. Orab	OH	Active
DSH360236B	Child	DSH	CLERMONT MERCY HOSPITAL	Mt. Orab Medical Center - Laboratory	154 Health Partners Circle	Mt Orab	OH	Terminated
DSH360236C	Child	DSH	CLERMONT MERCY HOSPITAL	Mercy Health - Bethel - Physical Therapy	720 W Plane Street, Suite 110	Bethel	OH	Terminated
DSH360236D	Child	DSH	CLERMONT MERCY HOSPITAL	MH-CLERMONT HOSPITAL WOUND CARE	3020 Hospital Dr	Batavia	OH	Active
DSH360236E	Child	DSH	CLERMONT MERCY HOSPITAL	MH-CLERMONT HOSPITAL WOUND CARE	3020 Hospital Dr	Batavia	OH	Active
DSH360236F	Child	DSH	CLERMONT MERCY HOSPITAL	Eastgate Surgery Center - Endoscopy	4415 Aicholtz Road	Cincinnati	OH	Terminated
DSH360236G	Child	DSH	CLERMONT MERCY HOSPITAL	Eastgate Surgery Center - Outpatient Surgery	4415 Aicholtz Road	Cincinnati	OH	Terminated
DSH360236H	Child	DSH	CLERMONT MERCY HOSPITAL	MH-CLERMONT HOSPITAL ANTICOAG CLIN	3020 Hospital Dr	Batavia	OH	Active
DSH360236J	Child	DSH	CLERMONT MERCY HOSPITAL	MH-MT. ORAB MEDICAL CENTER	154 Health Partners Cir	Mt. Orab	OH	Active
DSH360236K	Child	DSH	CLERMONT MERCY HOSPITAL	MERCY HEALTH - MILFORD IMAGING/LAB	201 OLD BANK RD	MILFORD	OH	Terminated
DSH360236L	Child	DSH	CLERMONT MERCY HOSPITAL	ONCOLOGY SERVICES - INFUSION THERAPY	3000 Hospital Drive	Batavia	OH	Terminated
DSH360236M	Child	DSH	CLERMONT MERCY HOSPITAL	MERCY HEALTH BHI - BEHAVIORAL HEALTH	3000 Hospital Drive	Batavia	OH	Terminated
DSH360236N	Child	DSH	CLERMONT MERCY HOSPITAL	SPECIALIZED SERVICES UNIT - AMBULATORY CARE	3000 Hospital Drive	Batavia	OH	Terminated
DSH360236P	Child	DSH	CLERMONT MERCY HOSPITAL	MERCY HEALTH - INFUSION AND CANCER CARE	4777 E Galbraith	Cincinnati	OH	Active
DSH360236Q	Child	DSH	CLERMONT MERCY HOSPITAL	MERCY CARE CLINIC - CLERMONT	3020 Hospital Dr	Batavia	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Reinstatement	Wagner, Emily ACFO Clermont Hospital BSMH 5137357548	Wagner, Emily CFO, Mercy Health - Tiffin & Willard Bon Secours Mercy Health 4194557053	7/12/2023 12:19 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Contacts	Authorizing Official	Update	AO Change Request	Sprague, Victor Assistant Chief Financial Officer Mercy Clermont Hospital 5137357548	Wagner, Emily ACFO Clermont Hospital BSMH 5137357548	3/28/2022 3:07 PM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/25/2022 12:00:00 AM	2/28/2022 3:04 PM
Details	State	Update	Termination Request	Active	To Be Terminated	2/28/2022 3:04 PM
Terminations	Termination Comments	Update	Termination Request		Within the 4 walls of the Hospital	2/28/2022 3:04 PM
Terminations	Termination Date	Update	Termination Request		4/1/2022 12:00:00 AM	2/28/2022 3:04 PM
Terminations	Termination Effective Date	Update	Termination Request		2/25/2022 12:00:00 AM	2/28/2022 3:04 PM
Terminations	Termination Reason	Update	Termination Request		Other	2/28/2022 3:04 PM
Details	Last Recertification Date	Update	Recertification	9/3/2020 11:16:28 AM	8/30/2021 1:11:46 PM	8/30/2021 1:11 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1568562551	9/3/2020 11:16 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/3/2020 11:16 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1568562551 ( )		9/3/2020 11:16 AM
Details	Last Recertification Date	Update	Recertification	8/27/2019 7:17:03 AM	9/3/2020 11:16:28 AM	9/3/2020 11:16 AM
Contacts	Authorizing Official	Update	Change Request	Lambert, Zachary Bates Chief Financial Officer Bon Secours Mercy Health - Clermont Hospital 5137357548	Sprague, Victor Assistant Chief Financial Officer Mercy Clermont Hospital 5137357548	1/28/2020 3:44 PM
Contacts	Primary Contact	Update	Recertification	Gordon, Amanda Pharmacy Director 340b Programs Mercy Health 5139525060	Dehner, Tab Director of Pharmacy Mercy Clermont Hospital 5137328670	8/27/2019 7:17 AM
Details	Last Recertification Date	Update	Recertification	8/27/2018 10:36:32 AM	8/27/2019 7:17:03 AM	8/27/2019 7:17 AM
Contacts	Authorizing Official	Update	Profile Change Request	Lambert, Zachary Bates Chief Financial Officer Bon Secours Mercy Health - Clermont Hospital 5136247548	Lambert, Zachary Bates Chief Financial Officer Bon Secours Mercy Health - Clermont Hospital 5137357548	8/26/2019 1:07 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1538619820 ( )		6/7/2019 6:56 AM
Contacts	Authorizing Official	Update	AO Change Request	Thomas, Laura Danielle CFO Mercy Health - East Market Cincinnati 5136243282	Lambert, Zachary Bates Chief Financial Officer Bon Secours Mercy Health - Clermont Hospital 5136247548	4/9/2019 10:21 AM
Contacts	Primary Contact	Update	Change Request	Carroll, Bill Director of Pharmacy Mercy Health Ohio 5137328670	Gordon, Amanda Pharmacy Director 340b Programs Mercy Health 5139525060	2/28/2019 1:52 PM
Details	Last Recertification Date	Update	Recertification		8/27/2018 10:36:32 AM	8/27/2018 10:36 AM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Thomas, Laura Danielle CFO Mercy Health - East Market Cincinnati 5136243282	5/2/2018 12:32 PM
Details	340B ID	Update	New Registration		DSH360236N	5/2/2018 12:32 PM
Details	Entity Subname	Update	New Registration	SPECIALIZED SERVICES UNIT	SPECIALIZED SERVICES UNIT - AMBULATORY CARE	5/2/2018 12:32 PM
Dates	Participating Approval Date	Update	New Registration		5/2/2018 12:32:20 PM	5/2/2018 12:32 PM
Details	State	Update	New Registration	Pending	Approved	5/2/2018 12:32 PM
Dates	Signed By Date	Update	New Registration		4/5/2018 11:21:58 AM	5/2/2018 12:32 PM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	5/2/2018 12:32 PM
Addresses	Main Address	Insert	New Registration		3000 Hospital Drive Batavia, OH 45103	4/5/2018 11:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2018 11:21 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0217447	4/5/2018 11:21 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/5/2018 11:21 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1568562551	4/5/2018 11:21 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1538619820	4/5/2018 11:21 AM
Contacts	Primary Contact	Insert	New Registration		Carroll, Bill Director of Pharmacy Mercy Health Ohio 5137328670	4/5/2018 11:21 AM
Contacts	Authorizing Official	Insert	New Registration		Thomas, Laura Danielle CFO Mercy Health - East Market Cincinnati 5136243282	4/5/2018 11:21 AM
Details	Last Recertification Date	Insert	New Registration			4/5/2018 11:21 AM
Details	Grant Number	Insert	New Registration			4/5/2018 11:21 AM
Details	340B ID	Insert	New Registration			4/5/2018 11:21 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/5/2018 11:21 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/5/2018 11:21 AM
Details	Medicare Provider Number	Insert	New Registration		360236	4/5/2018 11:21 AM
Details	Entity Name	Insert	New Registration		CLERMONT MERCY HOSPITAL	4/5/2018 11:21 AM
Details	Program Code	Insert	New Registration		DSH	4/5/2018 11:21 AM
Details	Entity Subname	Insert	New Registration		SPECIALIZED SERVICES UNIT	4/5/2018 11:21 AM
Dates	Participating Approval Date	Insert	New Registration			4/5/2018 11:21 AM
Details	State	Insert	New Registration		Pending	4/5/2018 11:21 AM
Dates	Registration Date	Insert	New Registration		4/5/2018 11:21:55 AM	4/5/2018 11:21 AM
Dates	Signed By Date	Insert	New Registration			4/5/2018 11:21 AM
Dates	Start Date	Insert	New Registration			4/5/2018 11:21 AM
Terminations	Termination Comments	Insert	New Registration			4/5/2018 11:21 AM
Terminations	Termination Date	Insert	New Registration			4/5/2018 11:21 AM
Terminations	Termination Effective Date	Insert	New Registration			4/5/2018 11:21 AM
Terminations	Termination Reason	Insert	New Registration			4/5/2018 11:21 AM