Covered Entity Details

DSH180051D JENNIE STUART MEDICAL CENTER (Active) - information as of 5/2/2025 10:35:17 PM

Main Details

Name

JENNIE STUART MEDICAL CENTER

Subdivision Name

JENNIE STUART FAMILY HEALTH - JENNIE STUART FAMILY HEALTH

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH180051D

Medicare Provider Number

180051

Outpatient Facility Provider Number

188556

Additional Details

Current Program Status

Active

Registration Date

7/12/2023

Participating Start Date

10/1/2023

Participating Approval Date

8/22/2023

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Jennie Stuart Medical Center
Beth McCraw, VP Nursing Services
(270) 887-0100 Ext: 1463

Primary Contact

Jennie Stuart Medical Center
Angela N Bradt, PharmD
(270) 887-0166

Addresses

Street Address

120 N. MAIN ST
TRENTON, KY 42286

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
KY	54013263,7100875720	1598708836,1235139312,1154045144,1912627605,1891415972,1679293369,1407576580

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
DSH180051B	Child	DSH	JENNIE STUART MEDICAL CENTER	Jennie Stuart Ambulatory Surgery Center	8250 Eagle Way	Hopkinsville	KY	Active
DSH180051C	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART GASTROENTEROLOGY - JENNIE STUART GASTROENTEROLOGY	231 BURLEY AVE	HOPKINSVILLE	KY	Active
DSH180051D	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART FAMILY HEALTH - JENNIE STUART FAMILY HEALTH	120 N. MAIN ST	TRENTON	KY	Active
DSH180051E	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART OBSTETRICS & GYNECOLOGY - JENNIE STUART OBSTETRICS & GYNECOLOGY	1621 NASHVILLE ST	RUSSELLVILLE	KY	Active
DSH180051F	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART OBSTETRICS & GYNECOLOGY - JENNIE STUART OBSTETRICS & GYNECOLOGY	1717 HIGH ST	HOPKINSVILLE	KY	Active
DSH180051G	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART UROLOGY - JENNIE STUART UROLOGY	1724 KENTON ST	HOPKINSVILLE	KY	Active
DSH180051H	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART FAMILY HEALTH - JENNIE STUART FAMILY HEALTH	105 KEETON DRIVE	HOPKINSVILLE	KY	Active
DSH180051J	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART ORTHOPAEDICS - JENNIE STUART ORTHOPEDICS	10755 EAGLE WAY	HOPKINSVILLE	KY	Active
DSH180051K	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART URGENT CARE - JENNIE STUART URGENT CARE	10755 EAGLE WAY	HOPKINSVILLE	KY	Active
DSH180051L	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART GEN SURGERY BARIATRIC - JENNIE STUART GENERAL SURGERY BARIATRIC	1724 KENTON ST	HOPKINSVILLE	KY	Active
DSH180051M	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART EAR, NOSE, AND THROAT - JENNNIE STUART EAR, NOSE, AND THROAT	10755 EAGLE WAY	HOPKINSVILLE	KY	Active
DSH180051N	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART MEDICAL ONCOLOGY - JENNIE STUART MEDICAL ONCOLOGY	1717 HIGH ST	HOPKINSVILLE	KY	Active
DSH180051P	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART GENERAL SURGERY - JENNIE STUART GENERAL SURGERY	1722 HIGH ST	HOPKINSVILLE	KY	Active
DSH180051Q	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART FAMILY HEALTH - JENNIE STUART FAMILY HEALTH	222 WEST 18TH STREET	HOPKINSVILLE	KY	Active
DSH180051R	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART DERMATOLOGY - JENNIE STUART DERMATOLOGY	10755 EAGLE WAY	HOPKINSVILLE	KY	Active
DSH180051S	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART NEUROLOGY - JENNIE STUART NEUROLOGY	1724 KENTON STREET	HOPKINSVILLE	KY	Active
DSH180051T	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART MOHS AND SKIN SURGERY - JENNIE STUART MOHS AND SKIN SURGERY	1717 HIGH STREET	HOPKINSVILLE	KY	Active
DSH180051U	Child	DSH	JENNIE STUART MEDICAL CENTER	JENNIE STUART MEDICAL CENTER INC - JENNIE STUART FAMILY HEALTH BURLEY AVENUE	227 BURLEY AVE	HOPKINSVILLE	KY	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/13/2024 11:07:08 AM	8/13/2024 11:07 AM
Contacts	Primary Contact	Update	Group Change Request	Osborn, Will Pharmacist jennie stuart medical center 2708870166	Bradt, Angela N PharmD Jennie Stuart Medical Center 2708870166	6/3/2024 7:55 AM
Contacts	Authorizing Official	Update	Profile Change Request	McCraw, Beth VP Nursing Services Jennie Stuart Medical Center 2708870100-1483	McCraw, Beth VP Nursing Services Jennie Stuart Medical Center 2708870100-1463	3/26/2024 11:14 AM
Contacts	Signed By	Update	Profile Change Request	McCraw, Beth VP Nursing Services Jennie Stuart Medical Center 2708870100-1483	McCraw, Beth VP Nursing Services Jennie Stuart Medical Center 2708870100-1463	3/26/2024 11:14 AM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		McCraw, Beth VP Nursing Services Jennie Stuart Medical Center 2708870100-1483	8/22/2023 7:50 AM
Details	340B ID	Update	New Registration		DSH180051D	8/22/2023 7:50 AM
Details	Entity Subname	Update	New Registration	JENNIE STUART FAMILY HEALTH	JENNIE STUART FAMILY HEALTH - JENNIE STUART FAMILY HEALTH	8/22/2023 7:50 AM
Dates	Participating Approval Date	Update	New Registration		8/22/2023 7:50:32 AM	8/22/2023 7:50 AM
Details	State	Update	New Registration	Pending	Approved	8/22/2023 7:50 AM
Dates	Signed By Date	Update	New Registration		7/28/2023 10:34:40 AM	8/22/2023 7:50 AM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	8/22/2023 7:50 AM
Addresses	Main Address	Insert	New Registration		120 N. MAIN ST TRENTON, KY 42286	7/12/2023 11:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2023 11:25 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		54013263	7/12/2023 11:25 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2023 11:25 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		7100875720	7/12/2023 11:25 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1598708836	7/12/2023 11:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1235139312	7/12/2023 11:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1154045144	7/12/2023 11:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1912627605	7/12/2023 11:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1891415972	7/12/2023 11:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1679293369	7/12/2023 11:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1407576580	7/12/2023 11:25 AM
Medicaid Billing	NPI: State	Insert	New Registration		KY	7/12/2023 11:25 AM
Contacts	Authorizing Official	Insert	New Registration		McCraw, Beth VP Nursing Services Jennie Stuart Medical Center 2708870100-1483	7/12/2023 11:25 AM
Contacts	Primary Contact	Insert	New Registration		Osborn, Will Pharmacist jennie stuart medical center 2708870166	7/12/2023 11:25 AM
Details	Assistance Received From Date	Insert	New Registration			7/12/2023 11:25 AM
Details	Assistance Received To Date	Insert	New Registration			7/12/2023 11:25 AM
Details	Last Recertification Date	Insert	New Registration			7/12/2023 11:25 AM
Details	Grant Number	Insert	New Registration			7/12/2023 11:25 AM
Details	340B ID	Insert	New Registration			7/12/2023 11:25 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/12/2023 11:25 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/12/2023 11:25 AM
Details	Medicare Provider Number	Insert	New Registration		180051	7/12/2023 11:25 AM
Details	Entity Name	Insert	New Registration		JENNIE STUART MEDICAL CENTER	7/12/2023 11:25 AM
Details	NOFO Number	Insert	New Registration			7/12/2023 11:25 AM
Details	Program Code	Insert	New Registration		DSH	7/12/2023 11:25 AM
Details	Entity Subname	Insert	New Registration		JENNIE STUART FAMILY HEALTH	7/12/2023 11:25 AM
Dates	Participating Approval Date	Insert	New Registration			7/12/2023 11:25 AM
Details	State	Insert	New Registration		Pending	7/12/2023 11:25 AM
Dates	Registration Date	Insert	New Registration		7/12/2023 11:25:56 AM	7/12/2023 11:25 AM
Dates	Signed By Date	Insert	New Registration			7/12/2023 11:25 AM
Dates	Start Date	Insert	New Registration			7/12/2023 11:25 AM
Terminations	Termination Comments	Insert	New Registration			7/12/2023 11:25 AM
Terminations	Termination Date	Insert	New Registration			7/12/2023 11:25 AM
Terminations	Termination Effective Date	Insert	New Registration			7/12/2023 11:25 AM
Terminations	Termination Reason	Insert	New Registration			7/12/2023 11:25 AM