Covered Entity Details

CAH141343-04 CRAWFORD HOSPITAL DISTRICT D/B/A CRAWFORD MEMORIAL HOSPITAL (Active) - information as of 6/19/2025 11:54:07 PM

Main Details

Name

CRAWFORD HOSPITAL DISTRICT D/B/A CRAWFORD MEMORIAL HOSPITAL

Subdivision Name

CRAWFORD HOSPITAL DISTRICT - Med Center Rural Health Clinic IV

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141343-04

Medicare Provider Number

141343

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/1/2022

Participating Start Date

7/1/2022

Participating Approval Date

4/13/2022

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Crawford Memorial Hospital
MITZI MARTIN, BOARD VICE CHAIR
(618) 544-3131 Ext: 5123

Primary Contact

Crawford Memorial Hospital
Blake Potts, Director of Pharmacy
(618) 544-3131 Ext: 5380

Addresses

Street Address

1000 N ALLEN ST
ROBINSON, IL 62454-1114

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
IL	370793762012	1356581540,1225028202,1609878420,1316345598,1467086892,1639443245,1063947067,1376170977

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
CAH141343-01	Child	CAH	CRAWFORD HOSPITAL DISTRICT D/B/A CRAWFORD MEMORIAL HOSPITAL	ROBINSON RURAL HEALTH CLINIC	1101 N. ALLEN STREET	ROBINSON	IL	Active
CAH141343-02	Child	CAH	CRAWFORD HOSPITAL DISTRICT D/B/A CRAWFORD MEMORIAL HOSPITAL	OBLONG RURAL HEALTH CLINIC	1366 E 1050th Ave.	OBLONG	IL	Active
CAH141343-03	Child	CAH	CRAWFORD HOSPITAL DISTRICT D/B/A CRAWFORD MEMORIAL HOSPITAL	PALESTINE RURAL HEALTH CLINIC	209 E. GRAND PRAIRIE STREET	PALESTINE	IL	Active
CAH141343-04	Child	CAH	CRAWFORD HOSPITAL DISTRICT D/B/A CRAWFORD MEMORIAL HOSPITAL	CRAWFORD HOSPITAL DISTRICT - Med Center Rural Health Clinic IV	1000 N ALLEN ST	ROBINSON	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 10:46:32 AM	8/19/2024 5:03:08 PM	8/19/2024 5:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1063947067	10/5/2023 9:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/5/2023 9:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1376170977	10/5/2023 9:28 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/5/2023 9:28 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 2:13:28 PM	8/16/2023 10:46:32 AM	8/16/2023 10:46 AM
Details	Last Recertification Date	Update	Recertification		8/29/2022 2:13:28 PM	8/29/2022 2:13 PM
Details	State	Update		Approved	Active	7/1/2022 12:01 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1225028202	6/15/2022 3:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/15/2022 3:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1609878420	6/15/2022 3:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/15/2022 3:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316345598	6/15/2022 3:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/15/2022 3:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1467086892	6/15/2022 3:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/15/2022 3:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639443245	6/15/2022 3:43 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	6/15/2022 3:43 PM
Contacts	Signed By	Insert	New Registration		MARTIN, MITZI BOARD VICE CHAIR Crawford Memorial Hospital 6185443131-5123	4/13/2022 8:08 AM
Details	340B ID	Update	New Registration		CAH141343-04	4/13/2022 8:08 AM
Details	Entity Name	Update	New Registration	CRAWFORD MEMORIAL HOSPITAL	CRAWFORD HOSPITAL DISTRICT D/B/A CRAWFORD MEMORIAL HOSPITAL	4/13/2022 8:08 AM
Details	Entity Subname	Update	New Registration	CRAWFORD HOSPITAL DISTRICT	CRAWFORD HOSPITAL DISTRICT - Med Center Rural Health Clinic IV	4/13/2022 8:08 AM
Dates	Participating Approval Date	Update	New Registration		4/13/2022 8:08:57 AM	4/13/2022 8:08 AM
Details	State	Update	New Registration	Pending	Approved	4/13/2022 8:08 AM
Dates	Signed By Date	Update	New Registration		4/11/2022 12:31:54 PM	4/13/2022 8:08 AM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	4/13/2022 8:08 AM
Addresses	Main Address	Insert	New Registration		1000 N ALLEN ST ROBINSON, IL 62454-1114	4/1/2022 10:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2022 10:25 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370793762012	4/1/2022 10:25 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/1/2022 10:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1356581540	4/1/2022 10:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/1/2022 10:25 AM
Contacts	Authorizing Official	Insert	New Registration		MARTIN, MITZI BOARD VICE CHAIR Crawford Memorial Hospital 6185443131-5123	4/1/2022 10:25 AM
Contacts	Primary Contact	Insert	New Registration		Potts, Blake Director of Pharmacy Crawford Memorial Hospital 6185443131-5380	4/1/2022 10:25 AM
Details	Assistance Received From Date	Insert	New Registration			4/1/2022 10:25 AM
Details	Assistance Received To Date	Insert	New Registration			4/1/2022 10:25 AM
Details	Last Recertification Date	Insert	New Registration			4/1/2022 10:25 AM
Details	Grant Number	Insert	New Registration			4/1/2022 10:25 AM
Details	340B ID	Insert	New Registration			4/1/2022 10:25 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2022 10:25 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2022 10:25 AM
Details	Medicare Provider Number	Insert	New Registration		141343	4/1/2022 10:25 AM
Details	Entity Name	Insert	New Registration		CRAWFORD MEMORIAL HOSPITAL	4/1/2022 10:25 AM
Details	NOFO Number	Insert	New Registration			4/1/2022 10:25 AM
Details	Program Code	Insert	New Registration		CAH	4/1/2022 10:25 AM
Details	Entity Subname	Insert	New Registration		CRAWFORD HOSPITAL DISTRICT	4/1/2022 10:25 AM
Dates	Participating Approval Date	Insert	New Registration			4/1/2022 10:25 AM
Details	State	Insert	New Registration		Pending	4/1/2022 10:25 AM
Dates	Registration Date	Insert	New Registration		4/1/2022 10:25:52 AM	4/1/2022 10:25 AM
Dates	Signed By Date	Insert	New Registration			4/1/2022 10:25 AM
Dates	Start Date	Insert	New Registration			4/1/2022 10:25 AM
Terminations	Termination Comments	Insert	New Registration			4/1/2022 10:25 AM
Terminations	Termination Date	Insert	New Registration			4/1/2022 10:25 AM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2022 10:25 AM
Terminations	Termination Reason	Insert	New Registration			4/1/2022 10:25 AM