Covered Entity Details

DSH020012E FAIRBANKS MEMORIAL HOSPITAL (Active) - information as of 6/6/2025 12:39:50 PM

Main Details

Name

FAIRBANKS MEMORIAL HOSPITAL

Subdivision Name

FHP BEHAVIOR HEALTH CLINIC - Behavioral Health & Addiction Medicine

Type

Disproportionate Share Hospital

Rural

340B ID

DSH020012E

Medicare Provider Number

020012

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/8/2024

Participating Start Date

1/1/2025

Participating Approval Date

11/18/2024

Last Recertification Date

Contacts

Authorizing Official

Fairbanks Memorial Hospital
Stephen L Duprey, Sr Director of Operations
(907) 458-3669 Ext: 73669

Primary Contact

Fairbanks Memorial Hospital
Marc J Rowden, Director of Pharmacy
(907) 458-5537

Addresses

Street Address

2111 COWLES ST
FAIRBANKS, AK 99701-5918

Billing Address

Fairbanks Memorial Hospital
1650 Cowles St
Fairbanks, AK 99701

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
AK	1655971	1720537178

Shipping Addresses

Shipping Address 1

Fairbanks Memorial Hospital Pharmacy
1650 Cowles St
Fairbanks, AK 99701

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
DSH020012A	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	Pain Treatment Center - Pain Treatment Center	1919 Lathrop St	Fairbanks	AK	Active
DSH020012B	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FMH Radiology Satellite - Radiology	1001 Noble Street	Fairbanks	AK	Terminated
DSH020012C	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FAIRBANKS MEMORIAL HOSPITAL - Internal Medicine, Senior Care & Medication Therapy Clinic	1919 LATHROP ST	FAIRBANKS	AK	Active
DSH020012D	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FHP ORTHOPEDIC & SPINE SPECIALIST - Orthopedics	1919 LATHROP ST	FAIRBANKS	AK	Active
DSH020012E	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FHP BEHAVIOR HEALTH CLINIC - Behavioral Health & Addiction Medicine	2111 COWLES ST	FAIRBANKS	AK	Active
DSH020012F	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FAIRBANKS MEMORIAL HOSPITAL - Osteopathic Manipulation Medicine	1919 LATHROP ST	FAIRBANKS	AK	Active
DSH020012G	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FAIRBANKS MEMORIAL HOSPITAL - Endocrinology & Diabetes Clinic	1919 LATHROP ST	FAIRBANKS	AK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Duprey, Stephen L Sr Director of Operations Fairbanks Memorial Hospital 9074583669-73669	11/18/2024 3:14 PM
Details	340B ID	Update	New Registration		DSH020012E	11/18/2024 3:14 PM
Details	Entity Name	Update	New Registration	FAIRBANKS MEMORIAL	FAIRBANKS MEMORIAL HOSPITAL	11/18/2024 3:14 PM
Details	Entity Subname	Update	New Registration	FHP BEHAVIOR HEALTH CLINIC	FHP BEHAVIOR HEALTH CLINIC - Behavioral Health & Addiction Medicine	11/18/2024 3:14 PM
Dates	Participating Approval Date	Update	New Registration		11/18/2024 3:14:00 PM	11/18/2024 3:14 PM
Details	State	Update	New Registration	Pending	Approved	11/18/2024 3:14 PM
Dates	Signed By Date	Update	New Registration		11/2/2024 12:05:54 AM	11/18/2024 3:14 PM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	11/18/2024 3:14 PM
Addresses	Main Address	Insert	New Registration		2111 COWLES ST FAIRBANKS, AK 99701-5918	10/8/2024 4:41 PM
Addresses	Billing Address	Insert	New Registration		Fairbanks Memorial Hospital 1650 Cowles St Fairbanks, AK 99701	10/8/2024 4:41 PM
Addresses	Shipping Address	Insert	New Registration		Fairbanks Memorial Hospital Pharmacy 1650 Cowles St Fairbanks, AK 99701	10/8/2024 4:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/8/2024 4:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1655971	10/8/2024 4:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	10/8/2024 4:41 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1720537178	10/8/2024 4:41 PM
Medicaid Billing	NPI: State	Insert	New Registration		AK	10/8/2024 4:41 PM
Contacts	Primary Contact	Insert	New Registration		Rowden, Marc J Director of Pharmacy Fairbanks Memorial Hospital 9074585537	10/8/2024 4:41 PM
Contacts	Authorizing Official	Insert	New Registration		Duprey, Stephen L Sr Director of Operations Fairbanks Memorial Hospital 9074583669-73669	10/8/2024 4:41 PM
Details	Assistance Received From Date	Insert	New Registration			10/8/2024 4:41 PM
Details	Assistance Received To Date	Insert	New Registration			10/8/2024 4:41 PM
Details	Last Recertification Date	Insert	New Registration			10/8/2024 4:41 PM
Details	Grant Number	Insert	New Registration			10/8/2024 4:41 PM
Details	340B ID	Insert	New Registration			10/8/2024 4:41 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/8/2024 4:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/8/2024 4:41 PM
Details	Medicare Provider Number	Insert	New Registration		020012	10/8/2024 4:41 PM
Details	Entity Name	Insert	New Registration		FAIRBANKS MEMORIAL	10/8/2024 4:41 PM
Details	NOFO Number	Insert	New Registration			10/8/2024 4:41 PM
Details	Program Code	Insert	New Registration		DSH	10/8/2024 4:41 PM
Details	Entity Subname	Insert	New Registration		FHP BEHAVIOR HEALTH CLINIC	10/8/2024 4:41 PM
Dates	Participating Approval Date	Insert	New Registration			10/8/2024 4:41 PM
Details	State	Insert	New Registration		Pending	10/8/2024 4:41 PM
Dates	Registration Date	Insert	New Registration		10/8/2024 4:41:12 PM	10/8/2024 4:41 PM
Dates	Signed By Date	Insert	New Registration			10/8/2024 4:41 PM
Dates	Start Date	Insert	New Registration			10/8/2024 4:41 PM
Terminations	Termination Comments	Insert	New Registration			10/8/2024 4:41 PM
Terminations	Termination Date	Insert	New Registration			10/8/2024 4:41 PM
Terminations	Termination Effective Date	Insert	New Registration			10/8/2024 4:41 PM
Terminations	Termination Reason	Insert	New Registration			10/8/2024 4:41 PM