Covered Entity Details

RRC010113-00 MOBILE INFIRMARY MEDICAL CENTER (Active) - information as of 6/12/2025 9:38:59 PM

Main Details

Name

MOBILE INFIRMARY MEDICAL CENTER

Subdivision Name

Type

Rural Referral Center

Rural

340B ID

RRC010113-00

Medicare Provider Number

010113

Additional Details

Current Program Status

Active

Registration Date

10/1/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/18/2024

Last Recertification Date

Contacts

Authorizing Official

Mobile Infirmary
Lee Ann Cain, Vice President
(251) 279-1510

Primary Contact

Mobile Infirmary
Michelle Wheat, 340B Coordinator
(251) 435-2683

Addresses

Street Address

FIVE MOBILE INFIRMARY CIRCLE
MOBILE, AL 36607

Billing Address

Mobile Infirmary Medical Center
PO Box 2144
Mobile, AL 36652

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
AL	HOS0113H	1558364802
FL	110578300	1558364802
MS	0020482	1558364802

Shipping Addresses

Shipping Address 1

MIMC RX4U
1 Mobile Infirmary Circle
Mobile, AL 36607

Shipping Address 2

iCare Discharge Pharmacy at MIMC
5 Mobile Infirmary Circle
Mobile, AL 36607

Shipping Address 3

MIMC RX4U at Saraland
95 Shell St.
Building B
Saraland, AL 36571

Shipping Address 4

Mobile Infirmary Medical Center
5 Mobile Infirmary Circle
Mobile, AL 36607

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
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/17/2025	07/01/2025			04/17/2025
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/17/2025	07/01/2025			04/17/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
RRC010113-01	Child	RRC	MOBILE INFIRMARY MEDICAL CENTER	Mobile Infirmary Infusion - infusion	1721 Springhill Avenue	Mobile	AL	Active
RRC010113-02	Child	RRC	MOBILE INFIRMARY MEDICAL CENTER	INFIRMARY IMAGING-HILLCREST - Radiology	845 HILLCREST RD	MOBILE	AL	Active
RRC010113-03	Child	RRC	MOBILE INFIRMARY MEDICAL CENTER	INFIRMARY 65 DIAGNOSTIC CENTER - PET/CT	3290 DAUPHIN ST	MOBILE	AL	Active
RRC010113-04	Child	RRC	MOBILE INFIRMARY MEDICAL CENTER	Mobile Infirmary Free Standing Emergency Department - Emergency	95 Shell Street, Building B	Saraland	AL	Active
RRC010113-05	Child	RRC	MOBILE INFIRMARY MEDICAL CENTER	INFIRMARY CENTER FOR WOUND HEALING - Provider Based Wound Care	1721 SPRING HILL AVE	MOBILE	AL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	FIVE MOBILE INFIRMARY CIRCLE MOBILE, AL 36652	FIVE MOBILE INFIRMARY CIRCLE MOBILE, AL 36607	1/22/2025 12:34 PM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Addresses	Shipping Address	Delete	Hospital Type Change Request	Mobile Infirmary Medical Center 5 Mobile Infirmary Circle Mobile, AL 36607		10/18/2024 9:37 AM
Addresses	Billing Address	Insert	Hospital Type Change Request		Mobile Infirmary Medical Center PO Box 2144 Mobile, AL 36652	10/18/2024 9:37 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		Mobile Infirmary Medical Center 5 Mobile Infirmary Circle Mobile, AL 36607	10/18/2024 9:37 AM
Contacts	Signed By	Insert	Hospital Type Change Request		Cain, Lee Ann Vice President Infirmary Health 2514354097	10/18/2024 9:37 AM
Details	340B ID	Update	Hospital Type Change Request		RRC010113-00	10/18/2024 9:37 AM
Dates	Participating Approval Date	Update	Hospital Type Change Request		10/18/2024 9:37:04 AM	10/18/2024 9:37 AM
Details	State	Update	Hospital Type Change Request	Pending	Approved	10/18/2024 9:37 AM
Dates	Signed By Date	Update	Hospital Type Change Request		10/10/2024 10:44:33 AM	10/18/2024 9:37 AM
Dates	Start Date	Update	Hospital Type Change Request		1/1/2025 12:00:00 AM	10/18/2024 9:37 AM
Addresses	Shipping Address	Delete	Hospital Type Change Request	Mobile Infirmary Medical Center 5 Mobile Infirmary Circle PO Box 2144 Mobile, AL 36607		10/10/2024 10:44 AM
Addresses	Billing Address	Insert	Hospital Type Change Request		Mobile Infirmary Medical Center PO Box 2144 Mobile, AL 36652	10/10/2024 10:44 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		Mobile Infirmary Medical Center 5 Mobile Infirmary Circle Mobile, AL 36607	10/10/2024 10:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/4/2024 1:31 PM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		0020482	10/4/2024 1:31 PM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		MS	10/4/2024 1:31 PM
Addresses	Main Address	Insert	Hospital Type Change Request		FIVE MOBILE INFIRMARY CIRCLE MOBILE, AL 36652	10/1/2024 9:13 AM
Addresses	Billing Address	Insert	Hospital Type Change Request		Mobile Infirmary Medical Center PO Box 2144 Mobile, AL 36652	10/1/2024 9:13 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		Mobile Infirmary Medical Center 5 Mobile Infirmary Circle PO Box 2144 Mobile, AL 36607	10/1/2024 9:13 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		MIMC RX4U 1 Mobile Infirmary Circle Mobile, AL 36607	10/1/2024 9:13 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		iCare Discharge Pharmacy at MIMC 5 Mobile Infirmary Circle Mobile, AL 36607	10/1/2024 9:13 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		MIMC RX4U at Saraland 95 Shell St. Building B Saraland, AL 36571	10/1/2024 9:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/1/2024 9:13 AM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		HOS0113H	10/1/2024 9:13 AM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		AL	10/1/2024 9:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	10/1/2024 9:13 AM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		110578300	10/1/2024 9:13 AM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		FL	10/1/2024 9:13 AM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1558364802	10/1/2024 9:13 AM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		AL	10/1/2024 9:13 AM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1558364802	10/1/2024 9:13 AM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		FL	10/1/2024 9:13 AM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1558364802	10/1/2024 9:13 AM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		MS	10/1/2024 9:13 AM
Contacts	Authorizing Official	Insert	Hospital Type Change Request		Cain, Lee Ann Vice President Infirmary Health 2514354097	10/1/2024 9:13 AM
Contacts	Primary Contact	Insert	Hospital Type Change Request		Wheat, Michelle 340B Coordinator Mobile Infirmary 2514352683	10/1/2024 9:13 AM
Details	Assistance Received From Date	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Details	Assistance Received To Date	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Details	Last Recertification Date	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Details	Grant Number	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Details	340B ID	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Details	Is Authorizing Official EHB Data	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Dates	Last Date That 340B Drugs Purchased	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Details	Medicare Provider Number	Insert	Hospital Type Change Request		010113	10/1/2024 9:13 AM
Details	Entity Name	Insert	Hospital Type Change Request		MOBILE INFIRMARY MEDICAL CENTER	10/1/2024 9:13 AM
Details	NOFO Number	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Details	Program Code	Insert	Hospital Type Change Request		RRC	10/1/2024 9:13 AM
Details	Entity Subname	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Dates	Participating Approval Date	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Details	State	Insert	Hospital Type Change Request		Pending	10/1/2024 9:13 AM
Dates	Registration Date	Insert	Hospital Type Change Request		10/1/2024 9:13:45 AM	10/1/2024 9:13 AM
Dates	Signed By Date	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Dates	Start Date	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Terminations	Termination Comments	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Terminations	Termination Date	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Terminations	Termination Effective Date	Insert	Hospital Type Change Request			10/1/2024 9:13 AM
Terminations	Termination Reason	Insert	Hospital Type Change Request			10/1/2024 9:13 AM