Covered Entity Details

CAH361301-04 Community Memorial Hospital (Terminated) - information as of 6/5/2025 2:40:42 PM

Main Details

Name

Community Memorial Hospital

Subdivision Name

COMMUNITY MEMORIAL HOSPITAL - Family Practice

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH361301-04

Medicare Provider Number

361301

Outpatient Facility Provider Number

363408

Additional Details

Current Program Status

Terminated

Registration Date

10/12/2020

Participating Start Date

1/1/2021

Participating Approval Date

10/23/2020

Last Recertification Date

8/16/2023

Termination Date
Termination Reason

10/1/2024
Failure to recertify

Contacts

Authorizing Official

Community Memorial Hospital
Benjamin Sheperd, Director of Pharmacy
(567) 239-1476

Primary Contact

Community Memorial Hospital
Amanda Rose, Controller
(419) 542-6628

Addresses

Street Address

208 COLUMBUS ST
HICKSVILLE, OH 43526-1250

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?
No

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
CAH361301-01	Child	CAH	Community Memorial Hospital	COMMUNITY MEMORIAL HOSPITAL - Family Practice	422 W RIVER ST	ANTWERP	OH	Terminated
CAH361301-02	Child	CAH	Community Memorial Hospital	COMMUNITY MEMORIAL HOSPITAL - Family Practice	104 N WEST ST	EDGERTON	OH	Terminated
CAH361301-03	Child	CAH	Community Memorial Hospital	COMMUNITY MEMORIAL HOSPITAL - Family Practice	107 BUFFALO STREET	ANTWERP	OH	Terminated
CAH361301-04	Child	CAH	Community Memorial Hospital	COMMUNITY MEMORIAL HOSPITAL - Family Practice	208 COLUMBUS ST	HICKSVILLE	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	Recertification		9/30/2024 12:00:00 AM	9/17/2024 1:02 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/17/2024 1:02 PM
Terminations	Termination Date	Update	Recertification		10/1/2024 12:00:00 AM	9/17/2024 1:02 PM
Terminations	Termination Effective Date	Update	Recertification		10/1/2024 12:00:00 AM	9/17/2024 1:02 PM
Terminations	Termination Reason	Update	Recertification		Failure to recertify	9/17/2024 1:02 PM
Contacts	Authorizing Official	Update	AO Change Request	Davis, Roy E CEO Community Memorial Hospital 4195425566	Sheperd, Benjamin Director of Pharmacy Community Memorial Hospital 5672391476	3/28/2024 10:19 AM
Contacts	Primary Contact	Update	Recertification	Stull, Kristi Controller Community Memorial Hospital 4195426692-5659	Rose, Amanda Controller Community Memorial Hospital 4195426628	8/16/2023 10:56 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 11:13:08 AM	8/16/2023 10:56:51 AM	8/16/2023 10:56 AM
Details	Last Recertification Date	Update	Recertification	8/18/2021 7:39:02 AM	9/13/2022 11:13:08 AM	9/13/2022 11:13 AM
Contacts	Authorizing Official	Update	AO Change Request	Fiser, Benjamin CIO Communtiy Memorial Hospital 4195425678	Davis, Roy E CEO Community Memorial Hospital 4195425566	9/13/2022 7:09 AM
Details	Last Recertification Date	Update	Recertification		8/18/2021 7:39:02 AM	8/18/2021 7:39 AM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Fiser, Benjamin CIO Communtiy Memorial Hospital 4195425678	10/23/2020 10:49 AM
Details	340B ID	Update	New Registration		CAH361301-04	10/23/2020 10:49 AM
Details	Entity Name	Update	New Registration	COMMUNITY MEMORIAL HOSPITAL	Community Memorial Hospital	10/23/2020 10:49 AM
Details	Entity Subname	Update	New Registration	COMMUNITY MEMORIAL HOSPITAL	COMMUNITY MEMORIAL HOSPITAL - Family Practice	10/23/2020 10:49 AM
Dates	Participating Approval Date	Update	New Registration		10/23/2020 10:49:55 AM	10/23/2020 10:49 AM
Details	State	Update	New Registration	Pending	Approved	10/23/2020 10:49 AM
Dates	Signed By Date	Update	New Registration		10/22/2020 9:20:44 AM	10/23/2020 10:49 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	10/23/2020 10:49 AM
Addresses	Main Address	Insert	New Registration		208 COLUMBUS ST HICKSVILLE, OH 43526-1250	10/12/2020 10:05 AM
Contacts	Primary Contact	Insert	New Registration		Stull, Kristi Controller Community Memorial Hospital 4195426692-5659	10/12/2020 10:05 AM
Contacts	Authorizing Official	Insert	New Registration		Fiser, Benjamin CIO Communtiy Memorial Hospital 4195425678	10/12/2020 10:05 AM
Details	Assistance Received From Date	Insert	New Registration			10/12/2020 10:05 AM
Details	Assistance Received To Date	Insert	New Registration			10/12/2020 10:05 AM
Details	Last Recertification Date	Insert	New Registration			10/12/2020 10:05 AM
Details	Grant Number	Insert	New Registration			10/12/2020 10:05 AM
Details	340B ID	Insert	New Registration			10/12/2020 10:05 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/12/2020 10:05 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/12/2020 10:05 AM
Details	Medicare Provider Number	Insert	New Registration		361301	10/12/2020 10:05 AM
Details	Entity Name	Insert	New Registration		COMMUNITY MEMORIAL HOSPITAL	10/12/2020 10:05 AM
Details	NOFO Number	Insert	New Registration			10/12/2020 10:05 AM
Details	Program Code	Insert	New Registration		CAH	10/12/2020 10:05 AM
Details	Entity Subname	Insert	New Registration		COMMUNITY MEMORIAL HOSPITAL	10/12/2020 10:05 AM
Dates	Participating Approval Date	Insert	New Registration			10/12/2020 10:05 AM
Details	State	Insert	New Registration		Pending	10/12/2020 10:05 AM
Dates	Registration Date	Insert	New Registration		10/12/2020 10:05:34 AM	10/12/2020 10:05 AM
Dates	Signed By Date	Insert	New Registration			10/12/2020 10:05 AM
Dates	Start Date	Insert	New Registration			10/12/2020 10:05 AM
Terminations	Termination Comments	Insert	New Registration			10/12/2020 10:05 AM
Terminations	Termination Date	Insert	New Registration			10/12/2020 10:05 AM
Terminations	Termination Effective Date	Insert	New Registration			10/12/2020 10:05 AM
Terminations	Termination Reason	Insert	New Registration			10/12/2020 10:05 AM