Covered Entity Details

RRC040010-14 MERCY MEDICAL CENTER (Active) - information as of 5/6/2025 11:08:13 PM

Main Details

Name

MERCY MEDICAL CENTER

Subdivision Name

MERCY HOSPITAL ROGERS - Interventional Pain Center Highway 102

Type

Rural Referral Center

Rural

340B ID

RRC040010-14

Medicare Provider Number

040010

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/13/2024

Participating Start Date

10/1/2024

Participating Approval Date

9/12/2024

Last Recertification Date

Contacts

Authorizing Official

Mercy
Greta Wilcher, Vice-President Finance
(479) 314-6100 Ext: 6104

Primary Contact

Mercy Shared Services
Mike Loftus, Director-Hospital Pharmacy
(417) 820-3487

Addresses

Street Address

3101 SE 14TH ST, PAIN MANAGEMENT HIGHWAY 102
BENTONVILLE, AR 72712-4900

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
AR	101109105	1316902414

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
RRC040010-01	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Sleep Center Physician Plaza	2708S RIFE MEDICAL LN	ROGERS	AR	Active
RRC040010-02	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Infusion Center Physicians Plaza	2708S RIFE MEDICAL LN	ROGERS	AR	Active
RRC040010-03	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Hyperbarics and Wound Physicians Plaza	2708S RIFE MEDICAL LN	ROGERS	AR	Active
RRC040010-04	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Endoscopy Physician Plaza	2708S RIFE MEDICAL LN	ROGERS	AR	Active
RRC040010-05	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Cardiac Rehabilitation Physician Plaza	2708S RIFE MEDICAL LN	ROGERS	AR	Active
RRC040010-06	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Nuclear Medicine Springdale	4600 MERCY LN	SPRINGDALE	AR	Active
RRC040010-07	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - MRI Springdale	4600 MERCY LN	SPRINGDALE	AR	Active
RRC040010-08	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Emergency Department Springdale	4600 MERCY LN	SPRINGDALE	AR	Active
RRC040010-09	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Echo/Stress Lab Springdale	4600 MERCY LN	SPRINGDALE	AR	Active
RRC040010-10	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - CT Scan Springdale	4600 MERCY LN	SPRINGDALE	AR	Active
RRC040010-11	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Mammography Highway 102	3101 SOUTHEAST 14TH STREET	BENTONVILLE	AR	Active
RRC040010-12	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - MRI Highway 102	3101 SOUTHEAST 14TH STREET	BENTONVILLE	AR	Active
RRC040010-13	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - CT Scan Highway 102	3101 SOUTHEAST 14TH STREET	BENTONVILLE	AR	Active
RRC040010-14	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Interventional Pain Center Highway 102	3101 SE 14TH ST, PAIN MANAGEMENT HIGHWAY 102	BENTONVILLE	AR	Active
RRC040010-15	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Therapy Services Horsebarn Road	1101S HORSEBARN RD	ROGERS	AR	Active
RRC040010-16	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Emergency Department Bella Vista	1 MERCY WAY	BELLA VISTA	AR	Active
RRC040010-17	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Echo Bella Vista	1 MERCY WAY	BELLA VISTA	AR	Active
RRC040010-18	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - CT Scan Bella Vista	1 MERCY WAY	BELLA VISTA	AR	Active
RRC040010-19	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Pulmonary Function Testing Sugar Creek	24 SUGAR CREEK CTR	BELLA VISTA	AR	Active
RRC040010-20	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - Surgery Center HWY 102	3101 SOUTHEAST 14TH STREET	BENTONVILLE	AR	Active
RRC040010-21	Child	RRC	MERCY MEDICAL CENTER	MERCY HOSPITAL ROGERS - THERAPY SERVICES SUGAR CREEK	24 SUGAR CREEK CTR	BELLA VISTA	AR	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Harmoning, Tammi Chief Financial Officer Mercy 4793382267	Wilcher, Greta Vice-President Finance Mercy 4793146100-6104	3/5/2025 8:58 PM
Details	State	Update		Approved	Active	10/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Harmoning, Tammi Chief Financial Officer Mercy 4793382267	9/12/2024 4:50 PM
Details	340B ID	Update	New Registration		RRC040010-14	9/12/2024 4:50 PM
Details	Entity Subname	Update	New Registration	MERCY HOSPITAL ROGERS	MERCY HOSPITAL ROGERS - Interventional Pain Center Highway 102	9/12/2024 4:50 PM
Dates	Participating Approval Date	Update	New Registration		9/12/2024 4:50:41 PM	9/12/2024 4:50 PM
Details	State	Update	New Registration	Pending	Approved	9/12/2024 4:50 PM
Dates	Signed By Date	Update	New Registration		7/15/2024 3:43:46 PM	9/12/2024 4:50 PM
Dates	Start Date	Update	New Registration		10/1/2024 12:00:00 AM	9/12/2024 4:50 PM
Addresses	Main Address	Insert	New Registration		3101 SE 14TH ST, PAIN MANAGEMENT HIGHWAY 102 BENTONVILLE, AR 72712-4900	7/13/2024 2:35 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/13/2024 2:35 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		101109105	7/13/2024 2:35 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	7/13/2024 2:35 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1316902414	7/13/2024 2:35 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	7/13/2024 2:35 PM
Contacts	Authorizing Official	Insert	New Registration		Harmoning, Tammi Chief Financial Officer Mercy 4793382267	7/13/2024 2:35 PM
Contacts	Primary Contact	Insert	New Registration		Loftus, Mike Director-Hospital Pharmacy Mercy Shared Services 4178203487	7/13/2024 2:35 PM
Details	Assistance Received From Date	Insert	New Registration			7/13/2024 2:35 PM
Details	Assistance Received To Date	Insert	New Registration			7/13/2024 2:35 PM
Details	Last Recertification Date	Insert	New Registration			7/13/2024 2:35 PM
Details	Grant Number	Insert	New Registration			7/13/2024 2:35 PM
Details	340B ID	Insert	New Registration			7/13/2024 2:35 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/13/2024 2:35 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/13/2024 2:35 PM
Details	Medicare Provider Number	Insert	New Registration		040010	7/13/2024 2:35 PM
Details	Entity Name	Insert	New Registration		MERCY MEDICAL CENTER	7/13/2024 2:35 PM
Details	NOFO Number	Insert	New Registration			7/13/2024 2:35 PM
Details	Program Code	Insert	New Registration		RRC	7/13/2024 2:35 PM
Details	Entity Subname	Insert	New Registration		MERCY HOSPITAL ROGERS	7/13/2024 2:35 PM
Dates	Participating Approval Date	Insert	New Registration			7/13/2024 2:35 PM
Details	State	Insert	New Registration		Pending	7/13/2024 2:35 PM
Dates	Registration Date	Insert	New Registration		7/13/2024 2:35:22 PM	7/13/2024 2:35 PM
Dates	Signed By Date	Insert	New Registration			7/13/2024 2:35 PM
Dates	Start Date	Insert	New Registration			7/13/2024 2:35 PM
Terminations	Termination Comments	Insert	New Registration			7/13/2024 2:35 PM
Terminations	Termination Date	Insert	New Registration			7/13/2024 2:35 PM
Terminations	Termination Effective Date	Insert	New Registration			7/13/2024 2:35 PM
Terminations	Termination Reason	Insert	New Registration			7/13/2024 2:35 PM