Covered Entity Details

DSH510013C REYNOLDS MEMORIAL HOSPITAL (Active) - information as of 5/10/2025 10:54:59 PM

Main Details

Name

REYNOLDS MEMORIAL HOSPITAL

Subdivision Name

REYNOLDS MEMORIAL HOSPITAL INC - Family Medicine 90.07

Type

Disproportionate Share Hospital

Rural

340B ID

DSH510013C

Medicare Provider Number

510013

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2021

Participating Start Date

7/1/2021

Participating Approval Date

6/3/2021

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Reynolds Memorial Hospital
Alex Craig Inclan, CFO
(304) 843-3240

Primary Contact

Reynolds Memorial Hospital
Terry Kennon, Director of Pharmacy
(304) 843-3309

Addresses

Street Address

426 8TH ST
STE 201
GLEN DALE, WV 26038-1451

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
WV		1144228305
OH		1144228305
PA		1144228305
VA		1144228305
KY		1144228305

Shipping Addresses

Shipping Address 1

West Virginia United Health System Inc DBA Enterprise Pharmacy Solutions
781 Chestnut Ridge Rd
Suite 600
Morgantown, WV 26505-0015

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
DSH510013A	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	REYNOLDS MEMORIAL HOSPITAL INC - Cancer Center	901 JEFFERSON AVE	GLEN DALE	WV	Active
DSH510013B	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	REYNOLDS MEMORIAL HOSPITAL INC - Family Medicine 90.04	426 8TH ST	GLEN DALE	WV	Active
DSH510013C	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	REYNOLDS MEMORIAL HOSPITAL INC - Family Medicine 90.07	426 8TH ST	GLEN DALE	WV	Active
DSH510013D	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	REYNOLDS MEMORIAL HOSPITAL INC - Internal Medicine 90.11	426 8TH ST	GLEN DALE	WV	Active
DSH510013E	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	Internal Medicine - St. Clairsville 90.17 - Internal Medicine	300 W Main St	St. Clairsville	OH	Terminated
DSH510013F	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	RMH Neurosurgery - Neurosurgery	426 8th Street	Glen Dale	WV	Active
DSH510013G	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	RMH Pain Clinic - Pain Clinic	426 8th Street	Glen Dale	WV	Active
DSH510013H	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	RMH Family Medicine - Family Medicine 90.06	426 8th Street	Glen Dale	WV	Active
DSH510013J	Child	DSH	REYNOLDS MEMORIAL HOSPITAL	RMH Family Medicine - Family Medicine 90.04-2	426 8th Street	Glen Dale	WV	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Group Change Request		West Virginia United Health System Inc DBA Enterprise Pharmacy Solutions 781 Chestnut Ridge Rd Suite 600 Morgantown, WV 26505-0015	10/23/2024 7:25 AM
Details	Last Recertification Date	Update	Recertification	8/17/2023 8:27:35 AM	8/13/2024 9:57:03 AM	8/13/2024 9:57 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0001309000 (WV)		6/6/2024 8:50 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	7306507 (OH)		6/6/2024 8:50 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1007753520001 (PA)		6/6/2024 8:50 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1144228305 (VA)		6/6/2024 8:50 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1144228305	6/6/2024 8:50 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/6/2024 8:50 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 8:07:37 AM	8/17/2023 8:27:35 AM	8/17/2023 8:27 AM
Details	Last Recertification Date	Update	Recertification	8/17/2021 8:42:50 AM	8/30/2022 8:07:37 AM	8/30/2022 8:07 AM
Details	Last Recertification Date	Update	Recertification		8/17/2021 8:42:50 AM	8/17/2021 8:42 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Inclan, Alex Craig CFO Reynolds Memorial Hospital 3048433240	6/3/2021 1:34 PM
Details	340B ID	Update	New Registration		DSH510013C	6/3/2021 1:34 PM
Details	Entity Subname	Update	New Registration	REYNOLDS MEMORIAL HOSPITAL INC	REYNOLDS MEMORIAL HOSPITAL INC - Family Medicine 90.07	6/3/2021 1:34 PM
Dates	Participating Approval Date	Update	New Registration		6/3/2021 1:34:14 PM	6/3/2021 1:34 PM
Details	State	Update	New Registration	Pending	Approved	6/3/2021 1:34 PM
Dates	Signed By Date	Update	New Registration		4/15/2021 10:40:24 AM	6/3/2021 1:34 PM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	6/3/2021 1:34 PM
Addresses	Main Address	Insert	New Registration		426 8TH ST STE 201 GLEN DALE, WV 26038-1451	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0001309000	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WV	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7306507	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007753520001	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1144228305	4/15/2021 10:17 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		VA	4/15/2021 10:17 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1144228305	4/15/2021 10:17 AM
Medicaid Billing	NPI: State	Insert	New Registration		WV	4/15/2021 10:17 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1144228305	4/15/2021 10:17 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	4/15/2021 10:17 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1144228305	4/15/2021 10:17 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/15/2021 10:17 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1144228305	4/15/2021 10:17 AM
Medicaid Billing	NPI: State	Insert	New Registration		VA	4/15/2021 10:17 AM
Contacts	Primary Contact	Insert	New Registration		Kennon, Terry Director of Pharmacy Reynolds Memorial Hospital 3048433309	4/15/2021 10:17 AM
Contacts	Authorizing Official	Insert	New Registration		Inclan, Alex Craig CFO Reynolds Memorial Hospital 3048433240	4/15/2021 10:17 AM
Details	Assistance Received From Date	Insert	New Registration			4/15/2021 10:17 AM
Details	Assistance Received To Date	Insert	New Registration			4/15/2021 10:17 AM
Details	Last Recertification Date	Insert	New Registration			4/15/2021 10:17 AM
Details	Grant Number	Insert	New Registration			4/15/2021 10:17 AM
Details	340B ID	Insert	New Registration			4/15/2021 10:17 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/15/2021 10:17 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/15/2021 10:17 AM
Details	Medicare Provider Number	Insert	New Registration		510013	4/15/2021 10:17 AM
Details	Entity Name	Insert	New Registration		REYNOLDS MEMORIAL HOSPITAL	4/15/2021 10:17 AM
Details	NOFO Number	Insert	New Registration			4/15/2021 10:17 AM
Details	Program Code	Insert	New Registration		DSH	4/15/2021 10:17 AM
Details	Entity Subname	Insert	New Registration		REYNOLDS MEMORIAL HOSPITAL INC	4/15/2021 10:17 AM
Dates	Participating Approval Date	Insert	New Registration			4/15/2021 10:17 AM
Details	State	Insert	New Registration		Pending	4/15/2021 10:17 AM
Dates	Registration Date	Insert	New Registration		4/15/2021 10:17:24 AM	4/15/2021 10:17 AM
Dates	Signed By Date	Insert	New Registration			4/15/2021 10:17 AM
Dates	Start Date	Insert	New Registration			4/15/2021 10:17 AM
Terminations	Termination Comments	Insert	New Registration			4/15/2021 10:17 AM
Terminations	Termination Date	Insert	New Registration			4/15/2021 10:17 AM
Terminations	Termination Effective Date	Insert	New Registration			4/15/2021 10:17 AM
Terminations	Termination Reason	Insert	New Registration			4/15/2021 10:17 AM