Covered Entity Details

DSH260017AG PHELPS COUNTY REGIONAL MEDICAL CNTR (Active) - information as of 4/25/2025 8:31:07 PM

Main Details

Name

PHELPS COUNTY REGIONAL MEDICAL CNTR

Subdivision Name

Phelps Health - Phelps Health Delbert Day Cancer Institute - Medical Oncology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260017AG

Medicare Provider Number

260017

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/12/2024

Participating Start Date

10/1/2024

Participating Approval Date

8/19/2024

Last Recertification Date

Contacts

Authorizing Official

Phelps County Regional Medical Center
Jana Cook, Chief Financial Officer
(573) 458-7916

Primary Contact

Phelps County Regional Medical Center
KREIG Leland MOORE, DIRECTOR OF PHARMACY
(573) 458-7892

Addresses

Street Address

1060 West 10th Street
Rolla, MO 65401

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
MO	010419109	1891766051

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
DSH260017A	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - ONCOLOGY SERVICES	1060 West 10th Street	Rolla	MO	Active
DSH260017AA	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Pain Clinic (Suite 330)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AB	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Pediatrics (Suite 300)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AC	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Waynesville Medical Plaza Family Medicine (Suite 200)	1000 GW Ln.	Waynesville	MO	Active
DSH260017AD	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Waynesville Medical Plaza Pediatrics (Suite 200)	1000 GW Ln.	Waynesville	MO	Active
DSH260017AE	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Waynesville Medical Plaza Specialty (Suite 250)	1000 GW Ln.	Waynesville	MO	Terminated
DSH260017AF	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Delbert Day Cancer Institute - Radiation Oncology (Ground Floor)	1060 W 10th Street	Rolla	MO	Active
DSH260017AG	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Delbert Day Cancer Institute - Medical Oncology	1060 West 10th Street	Rolla	MO	Active
DSH260017AH	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza Urology	1000 GW Ln.	Waynesville	MO	Active
DSH260017AJ	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza Nephrology	1000 GW Ln.	Waynesville	MO	Active
DSH260017AK	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza Pulmonology	1000 GW Ln.	Waynesville	MO	Active
DSH260017AL	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza Orthopedics	1000 GW Ln.	Waynesville	MO	Active
DSH260017AM	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS COUNTY REGIONAL MED. CENTER - Phelps Health Waynesville Medical Plaza Podiatry	1000 GW Ln.	Waynesville	MO	Active
DSH260017AN	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza General Surgery	1000 GW Ln.	Waynesville	MO	Active
DSH260017AP	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza ENT	1000 GW Ln.	Waynesville	MO	Active
DSH260017AQ	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Gerontology	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AR	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Family Medicine (Suite 380)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AS	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Podiatry (Suite 400)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017B	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Ambulatory Surgery Center	1050 West 10th Street	Rolla	MO	Active
DSH260017C	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Bond Building - Audiology	600 BLUES LAKE PKWY	ROLLA	MO	Active
DSH260017D	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Bond Building Family Medicine	600 BLUES LAKE PKWY	ROLLA	MO	Active
DSH260017E	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Bond Building Internal Medicine	600 BLUES LAKE PKWY	ROLLA	MO	Active
DSH260017F	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Allergy	1050 West 10th Street	ROLLA	MO	Active
DSH260017G	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health ENT	1050 W 10TH ST	ROLLA	MO	Active
DSH260017H	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Urology (Suite 150)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017J	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Gastroenterology (Suite 580)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017K	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Immediate Care Clinic - Waynesville (Suite 150)	1000 GW Ln.	Waynesville	MO	Active
DSH260017L	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Salem - Podiatry	1415 West Scenic Rivers Blvd.	Salem	MO	Active
DSH260017M	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Immediate Care Clinic - Rolla	603 South Bishop Ave	Rolla	MO	Active
DSH260017N	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Waynesville Medical Plaza - Women's Health	1000 GW Ln.	Waynesville	MO	Active
DSH260017P	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Physical Medicine and Rehabilitation (Suite 450)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017Q	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Nephrology (Suite 480)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017R	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Pulmonology (Suite 550)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017S	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Heart and Vascular Center (Suite 500)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017T	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Orthopedics (Suite 400)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017U	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Internal Medicine (Suite 350)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017V	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health General Surgery	1060 West 10th Street	Rolla	MO	Active
DSH260017W	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Women's Health and Maternity Services (Suite 510)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017X	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health St James - Behavioral Health	1000 N JEFFERSON ST	SAINT JAMES	MO	Terminated
DSH260017Y	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Salem Family Medicine Clinic	1415 West Scenic Rivers Blvd.	Salem	MO	Active
DSH260017Z	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health St James Family Medicine Clinic	1000 N JEFFERSON ST	SAINT JAMES	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Cook, Jana Chief Financial Officer Phelps County Regional Medical Center 5734587916	8/19/2024 2:11 PM
Details	340B ID	Update	New Registration		DSH260017AG	8/19/2024 2:11 PM
Details	Entity Subname	Update	New Registration	Phelps Health	Phelps Health - Phelps Health Delbert Day Cancer Institute - Medical Oncology	8/19/2024 2:11 PM
Dates	Participating Approval Date	Update	New Registration		8/19/2024 2:11:10 PM	8/19/2024 2:11 PM
Details	State	Update	New Registration	Pending	Approved	8/19/2024 2:11 PM
Dates	Signed By Date	Update	New Registration		8/17/2024 12:37:48 AM	8/19/2024 2:11 PM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	8/19/2024 2:11 PM
Addresses	Main Address	Insert	New Registration		1060 West 10th Street Rolla, MO 65401	7/12/2024 1:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2024 1:54 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010419109	7/12/2024 1:54 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	7/12/2024 1:54 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891766051	7/12/2024 1:54 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	7/12/2024 1:54 PM
Contacts	Primary Contact	Insert	New Registration		MOORE, KREIG Leland DIRECTOR OF PHARMACY Phelps County Regional Medical Center 5734587892	7/12/2024 1:54 PM
Contacts	Authorizing Official	Insert	New Registration		Cook, Jana Chief Financial Officer Phelps County Regional Medical Center 5734587916	7/12/2024 1:54 PM
Details	Assistance Received From Date	Insert	New Registration			7/12/2024 1:54 PM
Details	Assistance Received To Date	Insert	New Registration			7/12/2024 1:54 PM
Details	Last Recertification Date	Insert	New Registration			7/12/2024 1:54 PM
Details	Grant Number	Insert	New Registration			7/12/2024 1:54 PM
Details	340B ID	Insert	New Registration			7/12/2024 1:54 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/12/2024 1:54 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/12/2024 1:54 PM
Details	Medicare Provider Number	Insert	New Registration		260017	7/12/2024 1:54 PM
Details	Entity Name	Insert	New Registration		PHELPS COUNTY REGIONAL MEDICAL CNTR	7/12/2024 1:54 PM
Details	NOFO Number	Insert	New Registration			7/12/2024 1:54 PM
Details	Program Code	Insert	New Registration		DSH	7/12/2024 1:54 PM
Details	Entity Subname	Insert	New Registration		Phelps Health	7/12/2024 1:54 PM
Dates	Participating Approval Date	Insert	New Registration			7/12/2024 1:54 PM
Details	State	Insert	New Registration		Pending	7/12/2024 1:54 PM
Dates	Registration Date	Insert	New Registration		7/12/2024 1:54:44 PM	7/12/2024 1:54 PM
Dates	Signed By Date	Insert	New Registration			7/12/2024 1:54 PM
Dates	Start Date	Insert	New Registration			7/12/2024 1:54 PM
Terminations	Termination Comments	Insert	New Registration			7/12/2024 1:54 PM
Terminations	Termination Date	Insert	New Registration			7/12/2024 1:54 PM
Terminations	Termination Effective Date	Insert	New Registration			7/12/2024 1:54 PM
Terminations	Termination Reason	Insert	New Registration			7/12/2024 1:54 PM