Covered Entity Details

CAH181315-02 FORT LOGAN HOSPITAL (Active) - information as of 5/27/2025 2:41:40 PM

Main Details

Name

FORT LOGAN HOSPITAL

Subdivision Name

Liberty Family Medical Center - Liberty Family Medical Center

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH181315-02

Medicare Provider Number

181315

Outpatient Facility Provider Number

183430

Additional Details

Current Program Status

Active

Registration Date

4/5/2019

Participating Start Date

7/1/2019

Participating Approval Date

5/1/2019

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Fort Logan Hospital/James B. Haggin Hospital
Lynne Warner Lynn, Hospital Administrator
(859) 239-2329

Primary Contact

Ephraim McDowell Health
Megan N Curtis, 340B Program Coordinator
(859) 239-1727

Addresses

Street Address

511 Middleburg Street
Liberty, KY 42539

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
KY	35000686	1790932812

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
CAH181315-01	Child	CAH	FORT LOGAN HOSPITAL	Ephraim McDowell Garrard Clinic - Ephraim McDowell Garrard Clinic	405 Danville Street	Lancaster	KY	Active
CAH181315-02	Child	CAH	FORT LOGAN HOSPITAL	Liberty Family Medical Center - Liberty Family Medical Center	511 Middleburg Street	Liberty	KY	Active
CAH181315-03	Child	CAH	FORT LOGAN HOSPITAL	North Garrard Family Medical Center - North Garrard Family Medical Center	510 Camp Dick Road	Lancaster	KY	Active
CAH181315-04	Child	CAH	FORT LOGAN HOSPITAL	Stanford Medical Park - Stanford Medical Park	110 Metker Trail	Stanford	KY	Active
CAH181315-05	Child	CAH	FORT LOGAN HOSPITAL	RURAL HEALTH CLINIC - DANVILLE FAMILY PHYSICIANS	109 DANIEL DR	DANVILLE	KY	Active
CAH181315-06	Child	CAH	FORT LOGAN HOSPITAL	EPHRAIM MCDOWELL INTERNAL MEDICINE - CLINIC - EPHRAIM MCDOWELL INTERNAL MEDICINE	640 E LEXINGTON AVE	DANVILLE	KY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Haltom, Joan B System Director of Pharmacy Ephraim McDowell Health 8592391721	Curtis, Megan N 340B Program Coordinator Ephraim McDowell Health 8592391727	12/19/2024 8:58 AM
Details	Last Recertification Date	Update	Recertification	8/30/2023 10:33:15 PM	8/13/2024 5:11:31 PM	8/13/2024 5:11 PM
Contacts	Primary Contact	Update	Group Change Request	Curtis, Megan N 340B Program Coordinator Ephraim McDowell Health 8592391727	Haltom, Joan B System Director of Pharmacy Ephraim McDowell Health 8592391721	7/24/2024 6:51 AM
Contacts	Primary Contact	Update	Profile Change Request	Ballard, Megan N 340b Program Coordinator Ephraim McDowell Health 8592391727	Curtis, Megan N 340B Program Coordinator Ephraim McDowell Health 8592391727	9/7/2023 1:20 PM
Contacts	Authorizing Official	Update	Change Request	Dean, Jason Administrator Ephraim McDowell Fort Logan Hospital 6063654697	Lynn, Lynne Warner Hospital Administrator Fort Logan Hospital/James B. Haggin Hospital 8592392329	9/7/2023 12:05 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 1:11:49 PM	8/30/2023 10:33:15 PM	8/30/2023 10:33 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 3:43:36 PM	8/30/2022 1:11:49 PM	8/30/2022 1:11 PM
Contacts	Authorizing Official	Update	Change Request	Glass, Ina Louise Administrator Ephraim McDowell Fort Logan Hospital 6063654788	Dean, Jason Administrator Ephraim McDowell Fort Logan Hospital 6063654697	12/14/2021 3:14 PM
Details	Last Recertification Date	Update	Recertification	8/28/2020 10:51:24 AM	8/17/2021 3:43:36 PM	8/17/2021 3:43 PM
Medicaid Billing	NPI: State	Update	Recertification		KY	8/28/2020 10:51 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 12:22:56 PM	8/28/2020 10:51:24 AM	8/28/2020 10:51 AM
Contacts	Primary Contact	Update	Change Request	Kenney, Jaime P Primary contact Ephraim McDowell Fort Logan Hospital 6063654766	Ballard, Megan N 340b Program Coordinator Ephraim McDowell Health 8592391727	9/27/2019 2:15 PM
Details	Last Recertification Date	Update	Recertification		9/3/2019 12:22:56 PM	9/3/2019 12:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/5/2019 9:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		35000686	7/5/2019 9:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	7/5/2019 9:28 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1790932812	7/5/2019 9:28 AM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	01000223 (KY)		5/13/2019 1:26 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1689729832 ( )		5/13/2019 1:26 PM
Contacts	Signed By	Insert	New Registration		Glass, Ina Louise Administrator Ephraim McDowell Fort Logan Hospital 6063654788	5/1/2019 8:34 AM
Details	340B ID	Update	New Registration		CAH181315-02	5/1/2019 8:34 AM
Details	Entity Subname	Update	New Registration	Liberty Family Medical Center	Liberty Family Medical Center - Liberty Family Medical Center	5/1/2019 8:34 AM
Dates	Participating Approval Date	Update	New Registration		5/1/2019 8:34:51 AM	5/1/2019 8:34 AM
Details	State	Update	New Registration	Pending	Approved	5/1/2019 8:34 AM
Dates	Signed By Date	Update	New Registration		4/8/2019 9:26:24 AM	5/1/2019 8:34 AM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	5/1/2019 8:34 AM
Addresses	Main Address	Insert	New Registration		511 Middleburg Street Liberty, KY 42539	4/5/2019 4:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2019 4:17 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01000223	4/5/2019 4:17 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	4/5/2019 4:17 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1689729832	4/5/2019 4:17 PM
Contacts	Primary Contact	Insert	New Registration		Kenney, Jaime P Primary contact Ephraim McDowell Fort Logan Hospital 6063654766	4/5/2019 4:17 PM
Contacts	Authorizing Official	Insert	New Registration		Glass, Ina Louise Administrator Ephraim McDowell Fort Logan Hospital 6063654788	4/5/2019 4:17 PM
Details	Last Recertification Date	Insert	New Registration			4/5/2019 4:17 PM
Details	Grant Number	Insert	New Registration			4/5/2019 4:17 PM
Details	340B ID	Insert	New Registration			4/5/2019 4:17 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/5/2019 4:17 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/5/2019 4:17 PM
Details	Medicare Provider Number	Insert	New Registration		181315	4/5/2019 4:17 PM
Details	Entity Name	Insert	New Registration		FORT LOGAN HOSPITAL	4/5/2019 4:17 PM
Details	Program Code	Insert	New Registration		CAH	4/5/2019 4:17 PM
Details	Entity Subname	Insert	New Registration		Liberty Family Medical Center	4/5/2019 4:17 PM
Dates	Participating Approval Date	Insert	New Registration			4/5/2019 4:17 PM
Details	State	Insert	New Registration		Pending	4/5/2019 4:17 PM
Dates	Registration Date	Insert	New Registration		4/5/2019 4:17:27 PM	4/5/2019 4:17 PM
Dates	Signed By Date	Insert	New Registration			4/5/2019 4:17 PM
Dates	Start Date	Insert	New Registration			4/5/2019 4:17 PM
Terminations	Termination Comments	Insert	New Registration			4/5/2019 4:17 PM
Terminations	Termination Date	Insert	New Registration			4/5/2019 4:17 PM
Terminations	Termination Effective Date	Insert	New Registration			4/5/2019 4:17 PM
Terminations	Termination Reason	Insert	New Registration			4/5/2019 4:17 PM