Covered Entity Details

DSH040119V WHITE RIVER MEDICAL CENTER (Approved) - information as of 6/16/2025 11:19:34 PM

Main Details

Name

WHITE RIVER MEDICAL CENTER

Subdivision Name

WHITE RIVER HEALTH SYSTEM INC - Rural Health Clinic XII Newport

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH040119V

Medicare Provider Number

040119

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/10/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/15/2025

Last Recertification Date

Contacts

Authorizing Official

White River Health System
Shawna Jeffrey Ives, Controller
(870) 262-6100

Primary Contact

White River Medical Center
Maggie Williams, Pharmacy Director
(870) 262-6095

Addresses

Street Address

2200 MALCOLM AVE
STE B
NEWPORT, AR 72112-3697

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	163440002,333752729	1871609743,1710943881

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
DSH040119A	Child	DSH	WHITE RIVER MEDICAL CENTER	Midway Medical	195 Hospital Drive, Suite C	Cherokee Village	AR	Active
DSH040119B	Child	DSH	WHITE RIVER MEDICAL CENTER	Cave City Medical Clinic	301 S. Main St	Cave City	AR	Active
DSH040119C	Child	DSH	WHITE RIVER MEDICAL CENTER	Melbourne Medical Clinic	1526 East Main Street	Melbourne	AR	Active
DSH040119D	Child	DSH	WHITE RIVER MEDICAL CENTER	Pleasant Plains Medical Clinic	6200 Batesville Blvd	Pleasant Plains	AR	Active
DSH040119E	Child	DSH	WHITE RIVER MEDICAL CENTER	Drasco Medical Clinic	60 Greers Ferry Road	Drasco	AR	Active
DSH040119F	Child	DSH	WHITE RIVER MEDICAL CENTER	Strawberry Medical Clinic	58 East River Drive	Strawberry	AR	Active
DSH040119G	Child	DSH	WHITE RIVER MEDICAL CENTER	WRMC Cardiology	16 Hospital Circle, Suite A	BATESVILLE	AR	Active
DSH040119H	Child	DSH	WHITE RIVER MEDICAL CENTER	White River Medical Center Physicians Group/Pain Mgt.	1700 Harrison Street, Ste T	BATESVILLE	AR	Active
DSH040119J	Child	DSH	WHITE RIVER MEDICAL CENTER	Batesville Oncology Clinic	1710 HARRISON STREET	BATESVILLE	AR	Active
DSH040119K	Child	DSH	WHITE RIVER MEDICAL CENTER	WRMC Medical Complex Emergency Room	197 Hospital Dr. Suite C	Cherokee Village	AR	Active
DSH040119L	Child	DSH	WHITE RIVER MEDICAL CENTER	WRMC Neurology Clinic	1699 Harrison Sreet, Suite D	Batesville	AR	Active
DSH040119M	Child	DSH	WHITE RIVER MEDICAL CENTER	WRMC Internal Medicine Clinic	12 Hospital Circle, Suite B	Batesville	AR	Terminated
DSH040119N	Child	DSH	WHITE RIVER MEDICAL CENTER	WRMC Rheumatology Clinic	12 Hospital Circle, Suite A	Batesville	AR	Active
DSH040119P	Child	DSH	WHITE RIVER MEDICAL CENTER	Pulmonology Clinic II / Pulmonology	16 Hospital Circle, Suite C	Batesville	AR	Active
DSH040119Q	Child	DSH	WHITE RIVER MEDICAL CENTER	Family Care Clinic	1215 Sidney Street	Batesville	AR	Terminated
DSH040119R	Child	DSH	WHITE RIVER MEDICAL CENTER	WHITE RIVER HEALTH SYSTEM, INC. - Batesville Pulmonology Clinic WRMC Professional Building	255 Virginia Dr.	BATESVILLE	AR	Active
DSH040119S	Child	DSH	WHITE RIVER MEDICAL CENTER	WHITE RIVER HEALTH SYSTEM, INC. - Rural Health Clinic IX Virginia Dr	409 VIRGINIA DRIVE	BATESVILLE	AR	Active
DSH040119T	Child	DSH	WHITE RIVER MEDICAL CENTER	WHITE RIVER HEALTH SYSTEM, INC. - Rural Health Clinic VIII Southside	1217 BATESVILLE BOULEVARD SLOT 42	BATESVILLE	AR	Active
DSH040119U	Child	DSH	WHITE RIVER MEDICAL CENTER	WHITE RIVER HEALTH SYSTEM INC - Rural Health Clinic VII Newark	501 VINE STREET	NEWARK	AR	Active
DSH040119V	Child	DSH	WHITE RIVER MEDICAL CENTER	WHITE RIVER HEALTH SYSTEM INC - Rural Health Clinic XII Newport	2200 MALCOLM AVE	NEWPORT	AR	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Ives, Shawna Jeffrey Controller White River Health System 8702626100	4/15/2025 8:27 AM
Details	340B ID	Update	New Registration		DSH040119V	4/15/2025 8:27 AM
Details	Entity Subname	Update	New Registration	WHITE RIVER HEALTH SYSTEM INC	WHITE RIVER HEALTH SYSTEM INC - Rural Health Clinic XII Newport	4/15/2025 8:27 AM
Dates	Participating Approval Date	Update	New Registration		4/15/2025 8:27:28 AM	4/15/2025 8:27 AM
Details	State	Update	New Registration	Pending	Approved	4/15/2025 8:27 AM
Dates	Signed By Date	Update	New Registration		4/10/2025 5:39:19 PM	4/15/2025 8:27 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/15/2025 8:27 AM
Addresses	Main Address	Insert	New Registration		2200 MALCOLM AVE STE B NEWPORT, AR 72112-3697	4/10/2025 5:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/10/2025 5:16 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		163440002	4/10/2025 5:16 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	4/10/2025 5:16 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/10/2025 5:16 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		333752729	4/10/2025 5:16 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AR	4/10/2025 5:16 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1871609743	4/10/2025 5:16 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	4/10/2025 5:16 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1710943881	4/10/2025 5:16 PM
Medicaid Billing	NPI: State	Insert	New Registration		AR	4/10/2025 5:16 PM
Contacts	Primary Contact	Insert	New Registration		Williams, Maggie Pharmacy Director White River Medical Center 8702626095	4/10/2025 5:16 PM
Contacts	Authorizing Official	Insert	New Registration		Ives, Shawna Jeffrey Controller White River Health System 8702626100	4/10/2025 5:16 PM
Details	Assistance Received From Date	Insert	New Registration			4/10/2025 5:16 PM
Details	Assistance Received To Date	Insert	New Registration			4/10/2025 5:16 PM
Details	Last Recertification Date	Insert	New Registration			4/10/2025 5:16 PM
Details	Grant Number	Insert	New Registration			4/10/2025 5:16 PM
Details	340B ID	Insert	New Registration			4/10/2025 5:16 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/10/2025 5:16 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/10/2025 5:16 PM
Details	Medicare Provider Number	Insert	New Registration		040119	4/10/2025 5:16 PM
Details	Entity Name	Insert	New Registration		WHITE RIVER MEDICAL CENTER	4/10/2025 5:16 PM
Details	NOFO Number	Insert	New Registration			4/10/2025 5:16 PM
Details	Program Code	Insert	New Registration		DSH	4/10/2025 5:16 PM
Details	Entity Subname	Insert	New Registration		WHITE RIVER HEALTH SYSTEM INC	4/10/2025 5:16 PM
Dates	Participating Approval Date	Insert	New Registration			4/10/2025 5:16 PM
Details	State	Insert	New Registration		Pending	4/10/2025 5:16 PM
Dates	Registration Date	Insert	New Registration		4/10/2025 5:16:18 PM	4/10/2025 5:16 PM
Dates	Signed By Date	Insert	New Registration			4/10/2025 5:16 PM
Dates	Start Date	Insert	New Registration			4/10/2025 5:16 PM
Terminations	Termination Comments	Insert	New Registration			4/10/2025 5:16 PM
Terminations	Termination Date	Insert	New Registration			4/10/2025 5:16 PM
Terminations	Termination Effective Date	Insert	New Registration			4/10/2025 5:16 PM
Terminations	Termination Reason	Insert	New Registration			4/10/2025 5:16 PM