Covered Entity Details

CAH261311-16 Mercy Hospital Perry (Approved) - information as of 5/7/2025 10:39:39 PM

Main Details

Name

Mercy Hospital Perry

Subdivision Name

MERCY HOSPITAL PERRY - Infectious Disease

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH261311-16

Medicare Provider Number

261311

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/8/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/9/2025

Last Recertification Date

Contacts

Authorizing Official

Mercy
Sherry Clouse Day, VP Finance - Mercy CAH
(417) 820-8439

Primary Contact

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

Addresses

Street Address

212 HOSPITAL LN
STE 200
PERRYVILLE, MO 63775-4204

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	597917103	1639858855

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
CAH261311-01	Child	CAH	Mercy Hospital Perry	Mercy Primary Care	212 HOSPITAL LANE	PERRYVILLE	MO	Active
CAH261311-02	Child	CAH	Mercy Hospital Perry	Mercy Pulmonology and Dermatology	206 HOSPITAL LANE	PERRYVILLE	MO	Active
CAH261311-03	Child	CAH	Mercy Hospital Perry	Mercy Convenient Care	1508 Edgemont Blvd	Perryville	MO	Active
CAH261311-04	Child	CAH	Mercy Hospital Perry	Mercy Behavioral Health - RHC I	212 Hospital Lane	Perryville	MO	Active
CAH261311-05	Child	CAH	Mercy Hospital Perry	Mercy Infusion Center	210 Hospital Ln	Perryville	MO	Active
CAH261311-06	Child	CAH	Mercy Hospital Perry	Mercy Pediatrics	210 HOSPITAL LN	PERRYVILLE	MO	Active
CAH261311-07	Child	CAH	Mercy Hospital Perry	PERRY COUNTY HEALTH SYSTEM - General Surgery Suite 103	212 HOSPITAL LN	PERRYVILLE	MO	Active
CAH261311-08	Child	CAH	Mercy Hospital Perry	PERRY COUNTY HEALTH SYSTEM - Women's Health Suite 200	206 HOSPITAL LN STE 201	PERRYVILLE	MO	Active
CAH261311-09	Child	CAH	Mercy Hospital Perry	PERRY COUNTY HEALTH SYSTEM - Pain Management	206 HOSPITAL LN STE 204	PERRYVILLE	MO	Active
CAH261311-10	Child	CAH	Mercy Hospital Perry	PERRY COUNTY HEALTH SYSTEM - Orthopedics and Sports Medicine	206 HOSPITAL LN STE 202	PERRYVILLE	MO	Active
CAH261311-11	Child	CAH	Mercy Hospital Perry	PERRY COUNTY HEALTH SYSTEM - Podiatry Suite 200 RHC	212 HOSPITAL LN	PERRYVILLE	MO	Active
CAH261311-12	Child	CAH	Mercy Hospital Perry	PERRY COUNTY HEALTH SYSTEM - Urology	206 HOSPITAL LN STE 203	PERRYVILLE	MO	Active
CAH261311-13	Child	CAH	Mercy Hospital Perry	PERRY COUNTY HEALTH SYSTEM - Gastroenterology Suite 103 RHC	212 HOSPITAL LN	PERRYVILLE	MO	Active
CAH261311-14	Child	CAH	Mercy Hospital Perry	PERRY COUNTY HEALTH SYSTEM - Rheumatology Suite 202 RHC	212 HOSPITAL LN	PERRYVILLE	MO	Active
CAH261311-15	Child	CAH	Mercy Hospital Perry	MERCY HOSPITAL PERRY - Cardiology	212 HOSPITAL LN	PERRYVILLE	MO	Approved
CAH261311-16	Child	CAH	Mercy Hospital Perry	MERCY HOSPITAL PERRY - Infectious Disease	212 HOSPITAL LN	PERRYVILLE	MO	Approved
CAH261311-17	Child	CAH	Mercy Hospital Perry	MERCY HOSPITAL PERRY - Nephrology	206 HOSPITAL LN	PERRYVILLE	MO	Approved
CAH261311-18	Child	CAH	Mercy Hospital Perry	MERCY HOSPITAL PERRY - Ear, Nose, and Throat (ENT)	212 HOSPITAL LN	PERRYVILLE	MO	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Day, Sherry Clouse VP Finance - Mercy CAH Mercy 4178208439	4/9/2025 6:22 AM
Details	340B ID	Update	New Registration		CAH261311-16	4/9/2025 6:22 AM
Details	Entity Name	Update	New Registration	PERRY COUNTY MEMORIAL HOSPITAL	Mercy Hospital Perry	4/9/2025 6:22 AM
Details	Entity Subname	Update	New Registration	MERCY HOSPITAL PERRY	MERCY HOSPITAL PERRY - Infectious Disease	4/9/2025 6:22 AM
Dates	Participating Approval Date	Update	New Registration		4/9/2025 6:22:11 AM	4/9/2025 6:22 AM
Details	State	Update	New Registration	Pending	Approved	4/9/2025 6:22 AM
Dates	Signed By Date	Update	New Registration		4/8/2025 4:06:05 PM	4/9/2025 6:22 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/9/2025 6:22 AM
Addresses	Main Address	Insert	New Registration		212 HOSPITAL LN STE 200 PERRYVILLE, MO 63775-4204	4/8/2025 3:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/8/2025 3:10 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		597917103	4/8/2025 3:10 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	4/8/2025 3:10 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1639858855	4/8/2025 3:10 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	4/8/2025 3:10 PM
Contacts	Authorizing Official	Insert	New Registration		Day, Sherry Clouse VP Finance - Mercy CAH Mercy 4178208439	4/8/2025 3:10 PM
Contacts	Primary Contact	Insert	New Registration		Loftus, Mike Director-Hospital Pharmacy Mercy Shared Services 4178203487	4/8/2025 3:10 PM
Details	Assistance Received From Date	Insert	New Registration			4/8/2025 3:10 PM
Details	Assistance Received To Date	Insert	New Registration			4/8/2025 3:10 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2025 3:10 PM
Details	Grant Number	Insert	New Registration			4/8/2025 3:10 PM
Details	340B ID	Insert	New Registration			4/8/2025 3:10 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2025 3:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2025 3:10 PM
Details	Medicare Provider Number	Insert	New Registration		261311	4/8/2025 3:10 PM
Details	Entity Name	Insert	New Registration		PERRY COUNTY MEMORIAL HOSPITAL	4/8/2025 3:10 PM
Details	NOFO Number	Insert	New Registration			4/8/2025 3:10 PM
Details	Program Code	Insert	New Registration		CAH	4/8/2025 3:10 PM
Details	Entity Subname	Insert	New Registration		MERCY HOSPITAL PERRY	4/8/2025 3:10 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2025 3:10 PM
Details	State	Insert	New Registration		Pending	4/8/2025 3:10 PM
Dates	Registration Date	Insert	New Registration		4/8/2025 3:10:48 PM	4/8/2025 3:10 PM
Dates	Signed By Date	Insert	New Registration			4/8/2025 3:10 PM
Dates	Start Date	Insert	New Registration			4/8/2025 3:10 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2025 3:10 PM
Terminations	Termination Date	Insert	New Registration			4/8/2025 3:10 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2025 3:10 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2025 3:10 PM