Covered Entity Details

DSH260009F BOTHWELL REGIONAL HEALTH CENTER (Approved) - information as of 6/16/2025 2:17:41 AM

Main Details

Name

BOTHWELL REGIONAL HEALTH CENTER

Subdivision Name

BOTHWELL REGIONAL HTH CENTER - Wound Healing Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260009F

Medicare Provider Number

260009

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/8/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/14/2025

Last Recertification Date

Contacts

Authorizing Official

Bothwell Regional Health Center
Steven R Davis, Chief Financial Officer
(660) 829-7790

Primary Contact

Bothwell Regional Health Center
Jill Renae Weller, 340B Program Coordinator
(660) 827-9492

Addresses

Street Address

667 E 15TH ST
BOTHWELL WOUND CENTER
SEDALIA, MO 65301-7656

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	10157808	1235102690

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
DSH260009A	Child	DSH	BOTHWELL REGIONAL HEALTH CENTER	BRHC Pain Clinic - Pain Clinic	1430 Thompson Blvd	Sedalia	MO	Terminated
DSH260009B	Child	DSH	BOTHWELL REGIONAL HEALTH CENTER	BRHC Cole Camp Clinic - Family Practice / OB	1201 E Main St.	Cole Camp	MO	Active
DSH260009C	Child	DSH	BOTHWELL REGIONAL HEALTH CENTER	BRHC OB/GYN Clinic - OB/GYN	3401 W 10th	Sedalia	MO	Active
DSH260009D	Child	DSH	BOTHWELL REGIONAL HEALTH CENTER	BRHC Pediatric Clinic - Pediatric Clinic	2925 Clinton Rd.	Sedalia	MO	Active
DSH260009E	Child	DSH	BOTHWELL REGIONAL HEALTH CENTER	BOTHWELL HEALTH CENTER TRUMAN LAKE - Family Practice	1765 COMMERCIAL ST	WARSAW	MO	Active
DSH260009F	Child	DSH	BOTHWELL REGIONAL HEALTH CENTER	BOTHWELL REGIONAL HTH CENTER - Wound Healing Center	667 E 15TH ST	SEDALIA	MO	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Davis, Steven R Chief Financial Officer Bothwell Regional Health Center 6608297790	5/14/2025 1:13 PM
Details	340B ID	Update	New Registration		DSH260009F	5/14/2025 1:13 PM
Details	Entity Subname	Update	New Registration	BOTHWELL REGIONAL HTH CENTER	BOTHWELL REGIONAL HTH CENTER - Wound Healing Center	5/14/2025 1:13 PM
Dates	Participating Approval Date	Update	New Registration		5/14/2025 1:13:21 PM	5/14/2025 1:13 PM
Details	State	Update	New Registration	Pending	Approved	5/14/2025 1:13 PM
Dates	Signed By Date	Update	New Registration		4/10/2025 5:13:06 PM	5/14/2025 1:13 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/14/2025 1:13 PM
Addresses	Main Address	Insert	New Registration		667 E 15TH ST BOTHWELL WOUND CENTER SEDALIA, MO 65301-7656	4/8/2025 12:09 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 12:09 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		10157808	4/8/2025 12:09 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	4/8/2025 12:09 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1235102690	4/8/2025 12:09 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	4/8/2025 12:09 PM
Contacts	Authorizing Official	Insert	New Registration		Davis, Steven R Chief Financial Officer Bothwell Regional Health Center 6608297790	4/8/2025 12:09 PM
Contacts	Primary Contact	Insert	New Registration		Weller, Jill Renae 340B Program Coordinator Bothwell Regional Health Center 6608279492	4/8/2025 12:09 PM
Details	Assistance Received From Date	Insert	New Registration			4/8/2025 12:09 PM
Details	Assistance Received To Date	Insert	New Registration			4/8/2025 12:09 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2025 12:09 PM
Details	Grant Number	Insert	New Registration			4/8/2025 12:09 PM
Details	340B ID	Insert	New Registration			4/8/2025 12:09 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2025 12:09 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2025 12:09 PM
Details	Medicare Provider Number	Insert	New Registration		260009	4/8/2025 12:09 PM
Details	Entity Name	Insert	New Registration		BOTHWELL REGIONAL HEALTH CENTER	4/8/2025 12:09 PM
Details	NOFO Number	Insert	New Registration			4/8/2025 12:09 PM
Details	Program Code	Insert	New Registration		DSH	4/8/2025 12:09 PM
Details	Entity Subname	Insert	New Registration		BOTHWELL REGIONAL HTH CENTER	4/8/2025 12:09 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2025 12:09 PM
Details	State	Insert	New Registration		Pending	4/8/2025 12:09 PM
Dates	Registration Date	Insert	New Registration		4/8/2025 12:09:45 PM	4/8/2025 12:09 PM
Dates	Signed By Date	Insert	New Registration			4/8/2025 12:09 PM
Dates	Start Date	Insert	New Registration			4/8/2025 12:09 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2025 12:09 PM
Terminations	Termination Date	Insert	New Registration			4/8/2025 12:09 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2025 12:09 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2025 12:09 PM