| 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 Paducah Cancer Center - Oncology | MH - Paducah Cancer Center | 11/5/2024 10:16 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2023 3:03:58 PM | 8/29/2024 12:24:54 PM | 8/29/2024 12:24 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 |
| Addresses | Main Address | Update | Change Request |
225 Medical Center Dr.
Suite 301
Paducah, KY 42003 |
285 Medical Center Dr
Paducah, KY 42003 | 7/31/2024 7:40 AM |
| Addresses | Shipping Address | Delete | Change Request | Lourdes Hospital Oncology Pharmacy
225 Medical Center Dr
301
Paducah, KY 42003 | | 7/31/2024 7:40 AM |
| Details | Entity Subname | Update | Change Request | Mercy Health Paducah Medical Oncology & Hematology - Oncology | Mercy Health Paducah Cancer Center - Oncology | 7/31/2024 7:40 AM |
| Addresses | Shipping Address | Insert | Change Request | | Lourdes Hospital Oncology Pharmacy #2
285 Medical Center Drive
Paducah, KY 42003 | 5/3/2024 4:29 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2022 3:24:58 PM | 8/21/2023 3:03:58 PM | 8/21/2023 3:03 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 9:51:11 AM | 8/30/2022 3:24:58 PM | 8/30/2022 3:24 PM |
| Addresses | Shipping Address | Insert | Change Request | | Lourdes Hospital Oncology Pharmacy
225 Medical Center Dr
301
Paducah, KY 42003 | 11/5/2021 9:14 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/24/2021 9:51:11 AM | 8/24/2021 9:51 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 2:57 PM |
| Details | 340B ID | Update | New Registration | | DSH180102G | 6/3/2021 2:57 PM |
| Details | Entity Subname | Update | New Registration | Mercy Health Paducah Medical Oncology & Hematology | Mercy Health Paducah Medical Oncology & Hematology - Oncology | 6/3/2021 2:57 PM |
| Dates | Participating Approval Date | Update | New Registration | | 6/3/2021 2:57:04 PM | 6/3/2021 2:57 PM |
| Details | State | Update | New Registration | Pending | Approved | 6/3/2021 2:57 PM |
| Dates | Signed By Date | Update | New Registration | | 4/13/2021 3:16:22 PM | 6/3/2021 2:57 PM |
| Dates | Start Date | Update | New Registration | | 7/1/2021 12:00:00 AM | 6/3/2021 2:57 PM |
| Addresses | Main Address | Insert | New Registration | |
225 Medical Center Dr.
Suite 301
Paducah, KY 42003 | 4/13/2021 2:23 PM |
| Addresses | Billing Address | Insert | New Registration | | Mercy Health Lourdes Hospital LLC
1530 Lone Oak Road
Paducah, KY 42003 | 4/13/2021 2:23 PM |
| Addresses | Shipping Address | Insert | New Registration | | Mercy Health Lourdes Hospital LLC
1530 Lone Oak Road
Paducah, KY 42003 | 4/13/2021 2:23 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | New Registration | | False | 4/13/2021 2:23 PM |
| Medicaid Billing | Medicaid: Number | Insert | New Registration | | 01012152 | 4/13/2021 2:23 PM |
| Medicaid Billing | Medicaid: State | Insert | New Registration | | KY | 4/13/2021 2:23 PM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1346244126 | 4/13/2021 2:23 PM |
| Medicaid Billing | NPI: State | Insert | New Registration | | KY | 4/13/2021 2:23 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Archbold, Alan
Chief Financial Officer Kentucky Region
Lourdes Hospital
2704442553 | 4/13/2021 2:23 PM |
| Contacts | Primary Contact | Insert | New Registration | | Fish, Alisa
Director of Pharmacy
Mercy Health - Lourdes Hospital
2704442774 | 4/13/2021 2:23 PM |
| Details | Assistance Received From Date | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Details | Assistance Received To Date | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Details | Grant Number | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Details | 340B ID | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 180102 | 4/13/2021 2:23 PM |
| Details | Entity Name | Insert | New Registration | | MERCY HEALTH LOURDES HOSPITAL LLC | 4/13/2021 2:23 PM |
| Details | NOFO Number | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Details | Program Code | Insert | New Registration | | DSH | 4/13/2021 2:23 PM |
| Details | Entity Subname | Insert | New Registration | | Mercy Health Paducah Medical Oncology & Hematology | 4/13/2021 2:23 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Details | State | Insert | New Registration | | Pending | 4/13/2021 2:23 PM |
| Dates | Registration Date | Insert | New Registration | | 4/13/2021 2:23:16 PM | 4/13/2021 2:23 PM |
| Dates | Signed By Date | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Dates | Start Date | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Terminations | Termination Date | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 4/13/2021 2:23 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 4/13/2021 2:23 PM |