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DSH150064 FAYETTE MEMORIAL HOSPITAL ASSOCIATION (Terminated)
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Main Details
Name
FAYETTE MEMORIAL HOSPITAL ASSOCIATION
Subdivision Name
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH150064
Medicare Provider Number
150064
Additional Details
Current Program Status
Terminated
Registration Date
3/1/2006
Participating Start Date
4/1/2010
Participating Approval Date
3/30/2010
Last Recertification Date
9/4/2018
Termination Date
Termination Reason
10/1/2019
Failure to recertify
Contacts
Authorizing Official
Fayette Regional Health System
Samantha Bell, CFO
(765) 825-7709
Primary Contact
Fayette Regional Health
Tim Lakes, DIRECTOR OF PHARMACY SERVICES
(765) 825-8817
Addresses
Street Address
1941 VIRGINIA AVENUE
CONNERSVILLE, IN 47331
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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3/24/2010- DOCUMENT RECD. TO CONFIRM ELIG. DSH PERCENTAGE AND UPDATE AUTHORIZING OFFICIAL INFO; 3/29/10 REINSTATED-ORIG PART FROM 4/1/06 TO 12/31/09, INELIGIBLE 1/1/10 TO 3/31/10
04/05/2010
April 2025
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