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DSH360054DL HOLZER (Terminated)
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Main Details
Name
HOLZER
Subdivision Name
HOLZER / Pulmonology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH360054DL
Medicare Provider Number
360054
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/11/2021
Participating Start Date
4/1/2021
Participating Approval Date
3/3/2021
Last Recertification Date
9/8/2021
Termination Date
Termination Reason
10/1/2022
Site closure
Contacts
Authorizing Official
Holzer
Michael P Haynes, EVP/CFO
(740) 446-5743
Primary Contact
Holzer
Mary Ann Clemente, 340B Compliance Analyst
(740) 446-5803
Addresses
Street Address
280 PATTONSVILLE RD
JACKSON, OH 45640-9452
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (4/1/2015) until terminated effective date: (10/1/2019), reinstatement effective date: (04/01/2021).
02/16/2021
May 2025
May 2025
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