Covered Entity Details

CAH151331-04 HARRISON COUNTY HOSPITAL (Active) - information as of 5/3/2025 11:29:16 PM

Main Details

Name

HARRISON COUNTY HOSPITAL

Subdivision Name

First Capial Medical Group - Primary Care

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH151331-04

Medicare Provider Number

151331

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/8/2022

Participating Start Date

10/1/2022

Participating Approval Date

7/11/2022

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Harrison County Hospital
Lisa Marie Lieber, Chief Administrative Officer
(812) 738-7884

Primary Contact

Harrison County Hospital
Martin Cook, PHARMACY MANAGER
(812) 734-3749

Addresses

Street Address

1263 Hospital Dr NW
250
Corydon, IN 47112

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
IN	100268250A	1851378137
KY	01340306	1851378137

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
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 03280	255 OLD CAPITAL PLAZA NW	CORYDON	IN	47112	10/12/2023	01/01/2024			01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH151331-01	Child	CAH	HARRISON COUNTY HOSPITAL	Orthopedic Surgery - Orthopedic, Podiatry	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-02	Child	CAH	HARRISON COUNTY HOSPITAL	General Surgery - surgery	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-03	Child	CAH	HARRISON COUNTY HOSPITAL	Corydon Medical Associates - Internal Medicine, Sleep Medicine	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-04	Child	CAH	HARRISON COUNTY HOSPITAL	First Capial Medical Group - Primary Care	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-05	Child	CAH	HARRISON COUNTY HOSPITAL	OBGYN - Dr. Sauer - OBGYN	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-06	Child	CAH	HARRISON COUNTY HOSPITAL	Harrison Crawford Healthcare - Internal Medicine	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-07	Child	CAH	HARRISON COUNTY HOSPITAL	South Harrison Family Medicine - Primary Care	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-08	Child	CAH	HARRISON COUNTY HOSPITAL	Dermatology - Dermatology	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-09	Child	CAH	HARRISON COUNTY HOSPITAL	Kids First Pediatrics - Pediatrics	1263 Hospital Dr NW	Corydon	IN	Active
CAH151331-10	Child	CAH	HARRISON COUNTY HOSPITAL	HCH Elizabeth Clinic - Primary Care	5855 N. Highway 11 SE	Elizabeth	IN	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/21/2023 3:25:12 PM	8/13/2024 10:10:43 AM	8/13/2024 10:10 AM
Details	Last Recertification Date	Update	Recertification		8/21/2023 3:25:12 PM	8/21/2023 3:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/9/2023 3:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01340306	1/9/2023 3:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	1/9/2023 3:52 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851378137	1/9/2023 3:52 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	1/9/2023 3:52 PM
Details	State	Update		Approved	Active	10/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Lieber, Lisa Marie Chief Administrative Officer Harrison County Hospital 8127387884	7/11/2022 8:54 AM
Details	340B ID	Update	New Registration		CAH151331-04	7/11/2022 8:54 AM
Details	Entity Subname	Update	New Registration	First Capial Medical Group	First Capial Medical Group - Primary Care	7/11/2022 8:54 AM
Dates	Participating Approval Date	Update	New Registration		7/11/2022 8:54:42 AM	7/11/2022 8:54 AM
Details	State	Update	New Registration	Pending	Approved	7/11/2022 8:54 AM
Dates	Signed By Date	Update	New Registration		7/8/2022 2:49:00 PM	7/11/2022 8:54 AM
Dates	Start Date	Update	New Registration		10/1/2022 12:00:00 AM	7/11/2022 8:54 AM
Addresses	Main Address	Insert	New Registration		1263 Hospital Dr NW 250 Corydon, IN 47112	7/8/2022 2:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/8/2022 2:48 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100268250A	7/8/2022 2:48 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	7/8/2022 2:48 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1851378137	7/8/2022 2:48 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	7/8/2022 2:48 PM
Contacts	Primary Contact	Insert	New Registration		Cook, Martin PHARMACY MANAGER Harrison County Hospital 8127343749	7/8/2022 2:48 PM
Contacts	Authorizing Official	Insert	New Registration		Lieber, Lisa Marie Chief Administrative Officer Harrison County Hospital 8127387884	7/8/2022 2:48 PM
Details	Assistance Received From Date	Insert	New Registration			7/8/2022 2:48 PM
Details	Assistance Received To Date	Insert	New Registration			7/8/2022 2:48 PM
Details	Last Recertification Date	Insert	New Registration			7/8/2022 2:48 PM
Details	Grant Number	Insert	New Registration			7/8/2022 2:48 PM
Details	340B ID	Insert	New Registration			7/8/2022 2:48 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/8/2022 2:48 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/8/2022 2:48 PM
Details	Medicare Provider Number	Insert	New Registration		151331	7/8/2022 2:48 PM
Details	Entity Name	Insert	New Registration		HARRISON COUNTY HOSPITAL	7/8/2022 2:48 PM
Details	NOFO Number	Insert	New Registration			7/8/2022 2:48 PM
Details	Program Code	Insert	New Registration		CAH	7/8/2022 2:48 PM
Details	Entity Subname	Insert	New Registration		First Capial Medical Group	7/8/2022 2:48 PM
Dates	Participating Approval Date	Insert	New Registration			7/8/2022 2:48 PM
Details	State	Insert	New Registration		Pending	7/8/2022 2:48 PM
Dates	Registration Date	Insert	New Registration		7/8/2022 2:48:56 PM	7/8/2022 2:48 PM
Dates	Signed By Date	Insert	New Registration			7/8/2022 2:48 PM
Dates	Start Date	Insert	New Registration			7/8/2022 2:48 PM
Terminations	Termination Comments	Insert	New Registration			7/8/2022 2:48 PM
Terminations	Termination Date	Insert	New Registration			7/8/2022 2:48 PM
Terminations	Termination Effective Date	Insert	New Registration			7/8/2022 2:48 PM
Terminations	Termination Reason	Insert	New Registration			7/8/2022 2:48 PM