Covered Entity Details

DSH190208C EAST CARROLL PARISH HOSPITAL (Active) - information as of 6/12/2025 9:48:19 PM

Main Details

Name

EAST CARROLL PARISH HOSPITAL

Subdivision Name

East Carroll Medical Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH190208C

Medicare Provider Number

190208

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/13/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/23/2020

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

East Carroll Parish Hospital
LaDonna Englerth, Administrator
(318) 559-4023 Ext: 103

Primary Contact

East Carroll Parish Hospital
Tracie Russell, Pharmacy Manager
(318) 559-4023 Ext: 108

Addresses

Street Address

340 North Hood Street
Lake Providence, LA 71254

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
LA	1947873	1902885650

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
DSH190208A	Child	DSH	EAST CARROLL PARISH HOSPITAL	Family Medical Clinic - Primary Care	326 North Hood Street	Lake Providence	LA	Active
DSH190208B	Child	DSH	EAST CARROLL PARISH HOSPITAL	East Carroll Medical Clinic	340 North Hood Street	Lake Providence	LA	Active
DSH190208C	Child	DSH	EAST CARROLL PARISH HOSPITAL	East Carroll Medical Clinic	340 North Hood Street	Lake Providence	LA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/22/2023 9:15:07 AM	9/5/2024 10:57:26 AM	9/5/2024 10:57 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 4:00:53 PM	8/22/2023 9:15:07 AM	8/22/2023 9:15 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 11:23:41 AM	9/7/2022 4:00:53 PM	9/7/2022 4:00 PM
Addresses	Main Address	Update	Change Request	326 North Hood Street Lake Providence, LA 71254	340 North Hood Street Lake Providence, LA 71254	8/30/2021 1:24 PM
Contacts	Primary Contact	Update	Change Request	Martin, BeLynda Clinic Director East Carroll Parish Hospital 3185593303-203	Russell, Tracie Pharmacy Manager East Carroll Parish Hospital 3185594023-108	8/30/2021 1:24 PM
Details	Entity Subname	Update	Change Request	Family Practice Pediatric Clinic - Primary Care	East Carroll Medical Clinic	8/30/2021 1:24 PM
Details	Last Recertification Date	Update	Recertification	8/20/2020 11:35:27 AM	8/24/2021 11:23:41 AM	8/24/2021 11:23 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1902885650 ( )		8/20/2020 11:35 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1902885650	8/20/2020 11:35 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/20/2020 11:35 AM
Details	Last Recertification Date	Update	Recertification		8/20/2020 11:35:27 AM	8/20/2020 11:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/16/2020 10:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1947873	7/16/2020 10:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	7/16/2020 10:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1902885650	7/16/2020 10:06 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Contacts	Signed By	Insert	New Registration		Englerth, LaDonna Administrator East Carroll Parish Hospital 3185594023-103	4/23/2020 8:50 AM
Details	340B ID	Update	New Registration		DSH190208C	4/23/2020 8:50 AM
Details	Entity Subname	Update	New Registration	Family Practice Pediatric Clinic	Family Practice Pediatric Clinic - Primary Care	4/23/2020 8:50 AM
Dates	Participating Approval Date	Update	New Registration		4/23/2020 8:50:35 AM	4/23/2020 8:50 AM
Details	State	Update	New Registration	Pending	Approved	4/23/2020 8:50 AM
Dates	Signed By Date	Update	New Registration		4/22/2020 2:55:41 PM	4/23/2020 8:50 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/23/2020 8:50 AM
Addresses	Main Address	Insert	New Registration		326 North Hood Street Lake Providence, LA 71254	4/13/2020 3:57 PM
Contacts	Authorizing Official	Insert	New Registration		Englerth, LaDonna Administrator East Carroll Parish Hospital 3185594023-103	4/13/2020 3:57 PM
Contacts	Primary Contact	Insert	New Registration		Martin, BeLynda Clinic Director East Carroll Parish Hospital 3185593303-203	4/13/2020 3:57 PM
Details	Last Recertification Date	Insert	New Registration			4/13/2020 3:57 PM
Details	Grant Number	Insert	New Registration			4/13/2020 3:57 PM
Details	340B ID	Insert	New Registration			4/13/2020 3:57 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/13/2020 3:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/13/2020 3:57 PM
Details	Medicare Provider Number	Insert	New Registration		190208	4/13/2020 3:57 PM
Details	Entity Name	Insert	New Registration		EAST CARROLL PARISH HOSPITAL	4/13/2020 3:57 PM
Details	Program Code	Insert	New Registration		DSH	4/13/2020 3:57 PM
Details	Entity Subname	Insert	New Registration		Family Practice Pediatric Clinic	4/13/2020 3:57 PM
Dates	Participating Approval Date	Insert	New Registration			4/13/2020 3:57 PM
Details	State	Insert	New Registration		Pending	4/13/2020 3:57 PM
Dates	Registration Date	Insert	New Registration		4/13/2020 3:57:55 PM	4/13/2020 3:57 PM
Dates	Signed By Date	Insert	New Registration			4/13/2020 3:57 PM
Dates	Start Date	Insert	New Registration			4/13/2020 3:57 PM
Terminations	Termination Comments	Insert	New Registration			4/13/2020 3:57 PM
Terminations	Termination Date	Insert	New Registration			4/13/2020 3:57 PM
Terminations	Termination Effective Date	Insert	New Registration			4/13/2020 3:57 PM
Terminations	Termination Reason	Insert	New Registration			4/13/2020 3:57 PM