340B Drug Pricing Program Database
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DSH360054DD HOLZER (Terminated)
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Main Details
Name
HOLZER
Subdivision Name
HOLZER / Sycamore Cardiology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH360054DD
Medicare Provider Number
360054
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/11/2022
Participating Start Date
7/1/2022
Participating Approval Date
4/29/2022
Last Recertification Date
9/6/2023
Termination Date
Termination Reason
10/1/2024
Business decision by the Covered Entity
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
1051 4TH AVE
GALLIPOLIS, OH 45631-1612
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: (07/1/2022)
04/28/2022
May 2025
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