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RRC180102-09 MERCY HEALTH LOURDES HOSPITAL LLC (Terminated)
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Main Details
Name
MERCY HEALTH LOURDES HOSPITAL LLC
Subdivision Name
Lourdes Imaging - Benton
Type
Rural Referral Center
Rural
Yes
340B ID
RRC180102-09
Medicare Provider Number
180102
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/17/2016
Participating Start Date
1/1/2017
Participating Approval Date
10/28/2016
Last Recertification Date
11/6/2017
Termination Date
Termination Reason
10/1/2018
Business decision by the Covered Entity
Contacts
Authorizing Official
Lourdes Hospital
Alan Archbold, Chief Financial Officer Kentucky Region
(270) 444-2553
Primary Contact
Mercy Health Lourdes Hospital LLC
Keithen Branch, Director of Pharmacy
(270) 444-2774
Addresses
Street Address
83 Wellness Way
Suite 4
Benton, KY 42025-7156
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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May 2025
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