Covered Entity Details

DSH180102H MERCY HEALTH LOURDES HOSPITAL LLC (Active) - information as of 5/22/2025 11:58:53 PM

Main Details

Name

MERCY HEALTH LOURDES HOSPITAL LLC

Subdivision Name

MH - Physical & Pain Medicine

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH180102H

Medicare Provider Number

180102

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/13/2021

Participating Start Date

7/1/2021

Participating Approval Date

6/3/2021

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Bon Secours Mercy Health
Daniel Thomas Warren, Market CFO
(270) 444-2553

Primary Contact

Bon Secours Mercy Health
Sarah Lee Forthman, Director of Pharmacy
(270) 444-2289

Addresses

Street Address

1532 Lone Oak Rd
Suite 320
Paducah, KY 42003

Billing Address

Mercy Health Lourdes Hospital LLC
1530 Lone Oak Road
Paducah, KY 42003

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	01012152	1346244126

Shipping Addresses

Shipping Address 1

Mercy Health Lourdes Hospital LLC
1530 Lone Oak Road
Paducah, KY 42003

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
DSH180102A	Child	DSH	MERCY HEALTH LOURDES HOSPITAL LLC	Lourdes Behavioral Health Outpatient - Lourdes Behavioral Health Outpatient	1532 Lone Oak Rd	Paducah	KY	Terminated
DSH180102B	Child	DSH	MERCY HEALTH LOURDES HOSPITAL LLC	MH - Paducah Pain Medicine	1532 Lone Oak Rd.	Paducah	KY	Active
DSH180102C	Child	DSH	MERCY HEALTH LOURDES HOSPITAL LLC	Outpatient Infusion Therapy - Outpatient Infusion Therapy	1532 Lone Oak Rd.	Paducah	KY	Active
DSH180102D	Child	DSH	MERCY HEALTH LOURDES HOSPITAL LLC	Lourdes Women's Center - Lourdes Women's Center	1532 Lone Oak Road	Paducah	KY	Terminated
DSH180102E	Child	DSH	MERCY HEALTH LOURDES HOSPITAL LLC	MH - Paducah Wound Care & Hyperbaric	225 Medical Center Dr.	Paducah	KY	Active
DSH180102F	Child	DSH	MERCY HEALTH LOURDES HOSPITAL LLC	Cardiology & Vascular Testing / LMP Vascular Lab - Cardiology & Vascular Testing / LMP Vascular Lab	225 Medical Center Dr.	Paducah	KY	Terminated
DSH180102G	Child	DSH	MERCY HEALTH LOURDES HOSPITAL LLC	MH - Paducah Cancer Center	285 Medical Center Dr	Paducah	KY	Active
DSH180102H	Child	DSH	MERCY HEALTH LOURDES HOSPITAL LLC	MH - Physical & Pain Medicine	1532 Lone Oak Rd	Paducah	KY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	PC Change Request	Fairfield, Autumn 340B Manager Bon Secours Mercy Health 2702174090	Forthman, Sarah Lee Director of Pharmacy Bon Secours Mercy Health 2704442289	11/7/2024 7:53 AM
Details	Entity Subname	Update	Change Request	Mercy Health Physical and Pain Medicine - Pain Medicine	MH - Physical & Pain Medicine	11/5/2024 10:16 AM
Details	Last Recertification Date	Update	Recertification	8/21/2023 3:09:07 PM	8/29/2024 12:26:57 PM	8/29/2024 12:26 PM
Contacts	Primary Contact	Update	Group Change Request	Fish, Alisa Director of Pharmacy Mercy Health - Lourdes Hospital 2704442774	Fairfield, Autumn 340B Manager Bon Secours Mercy Health 2702174090	8/9/2024 2:58 PM
Details	Last Recertification Date	Update	Recertification	8/30/2022 3:25:32 PM	8/21/2023 3:09:07 PM	8/21/2023 3:09 PM
Contacts	Authorizing Official	Update	AO Change Request	Seminaro, Anthony CFO, Markets Bon Secours Mercy Health 9415871220	Warren, Daniel Thomas Market CFO Bon Secours Mercy Health 2704442553	5/10/2023 12:27 PM
Contacts	Authorizing Official	Update	AO Change Request	Archbold, Alan Chief Financial Officer Kentucky Region Lourdes Hospital 2704442553	Seminaro, Anthony CFO, Markets Bon Secours Mercy Health 9415871220	11/16/2022 7:10 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 9:53:29 AM	8/30/2022 3:25:32 PM	8/30/2022 3:25 PM
Details	Last Recertification Date	Update	Recertification		8/24/2021 9:53:29 AM	8/24/2021 9:53 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Archbold, Alan Chief Financial Officer Kentucky Region Lourdes Hospital 2704442553	6/3/2021 1:42 PM
Details	340B ID	Update	New Registration		DSH180102H	6/3/2021 1:42 PM
Details	Entity Subname	Update	New Registration	Mercy Health Physical and Pain Medicine	Mercy Health Physical and Pain Medicine - Pain Medicine	6/3/2021 1:42 PM
Dates	Participating Approval Date	Update	New Registration		6/3/2021 1:42:56 PM	6/3/2021 1:42 PM
Details	State	Update	New Registration	Pending	Approved	6/3/2021 1:42 PM
Dates	Signed By Date	Update	New Registration		4/13/2021 3:17:42 PM	6/3/2021 1:42 PM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	6/3/2021 1:42 PM
Addresses	Main Address	Insert	New Registration		1532 Lone Oak Rd Suite 320 Paducah, KY 42003	4/13/2021 2:17 PM
Addresses	Billing Address	Insert	New Registration		Mercy Health Lourdes Hospital LLC 1530 Lone Oak Road Paducah, KY 42003	4/13/2021 2:17 PM
Addresses	Shipping Address	Insert	New Registration		Mercy Health Lourdes Hospital LLC 1530 Lone Oak Road Paducah, KY 42003	4/13/2021 2:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2021 2:17 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01012152	4/13/2021 2:17 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	4/13/2021 2:17 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1346244126	4/13/2021 2:17 PM
Medicaid Billing	NPI: State	Insert	New Registration		KY	4/13/2021 2:17 PM
Contacts	Authorizing Official	Insert	New Registration		Archbold, Alan Chief Financial Officer Kentucky Region Lourdes Hospital 2704442553	4/13/2021 2:17 PM
Contacts	Primary Contact	Insert	New Registration		Fish, Alisa Director of Pharmacy Mercy Health - Lourdes Hospital 2704442774	4/13/2021 2:17 PM
Details	Assistance Received From Date	Insert	New Registration			4/13/2021 2:17 PM
Details	Assistance Received To Date	Insert	New Registration			4/13/2021 2:17 PM
Details	Last Recertification Date	Insert	New Registration			4/13/2021 2:17 PM
Details	Grant Number	Insert	New Registration			4/13/2021 2:17 PM
Details	340B ID	Insert	New Registration			4/13/2021 2:17 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/13/2021 2:17 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/13/2021 2:17 PM
Details	Medicare Provider Number	Insert	New Registration		180102	4/13/2021 2:17 PM
Details	Entity Name	Insert	New Registration		MERCY HEALTH LOURDES HOSPITAL LLC	4/13/2021 2:17 PM
Details	NOFO Number	Insert	New Registration			4/13/2021 2:17 PM
Details	Program Code	Insert	New Registration		DSH	4/13/2021 2:17 PM
Details	Entity Subname	Insert	New Registration		Mercy Health Physical and Pain Medicine	4/13/2021 2:17 PM
Dates	Participating Approval Date	Insert	New Registration			4/13/2021 2:17 PM
Details	State	Insert	New Registration		Pending	4/13/2021 2:17 PM
Dates	Registration Date	Insert	New Registration		4/13/2021 2:17:09 PM	4/13/2021 2:17 PM
Dates	Signed By Date	Insert	New Registration			4/13/2021 2:17 PM
Dates	Start Date	Insert	New Registration			4/13/2021 2:17 PM
Terminations	Termination Comments	Insert	New Registration			4/13/2021 2:17 PM
Terminations	Termination Date	Insert	New Registration			4/13/2021 2:17 PM
Terminations	Termination Effective Date	Insert	New Registration			4/13/2021 2:17 PM
Terminations	Termination Reason	Insert	New Registration			4/13/2021 2:17 PM