Covered Entity Details

CH07440A DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC. (Active) - information as of 4/29/2025 2:49:50 AM

Main Details

Name

DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.

Subdivision Name

DOUGLAS COUNTY PUBLIC HEALTH

Type

HRSA-Funded Health Center

Site ID

BPS-H80-001447

340B ID

CH07440A

Grant Number

H80CS00457

Additional Details

Current Program Status

Active

Registration Date

4/1/2004

Participating Start Date

4/1/2004

Participating Approval Date

3/25/2004

Last Recertification Date

2/25/2025

Contacts

Authorizing Official

Missouri Ozarks Community Health
Randall L Gann, CEO
(417) 683-5739

Primary Contact

Douglas County Public Health Services Group, INc.
Jennifer Heinlein, COO
(417) 683-5739 Ext: 1111

Addresses

Street Address

504 W. Broadway Ave.
AVA, MO 65608-1359

Billing Address

Missouri Ozarks Community Health
PO Box 1359
Ava, MO 65608

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
10/10/08 ADDED MEDICAID #S; 10/7/2008 ADDED IN HOUSE PHARMACY AS SHIPPING ADDR.	01/11/2010

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	505408500,605408509	1912904145,1326158957

Shipping Addresses

Shipping Address 1

MOCH PHARMACY
504 W. Broadway Ave.
AVA, MO 65608

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	SUPER D DRUGS ACQUISITION CO.	AVA DRUG #15726, POWERED BY WALGREENS	124 W WASHINGTON AVE	AVA	MO	65608	04/13/2015	07/01/2015		04/13/2015
Contract Detail	SUPER D DRUGS ACQUISITION CO.	MANSFIELD DRUG #15731	POWERED BY WALGREENS 101 N BUSINESS HWY 60	MANSFIELD	MO	65704	04/13/2015	07/01/2015		04/13/2015
Contract Detail	SUPER D DRUGS ACQUISITION CO.	SEYMOUR PHARMACY #15732	POWERED BY WALGREENS 214 S. MAIN STREET	SEYMOUR	MO	65746	04/13/2015	07/01/2015		04/13/2015
Contract Detail	WALGREEN CO.	FORBES PHARMACY #15722, POWERED BY WALGR	100 NORTH GRAND	HOUSTON	MO	65483	10/15/2019	01/01/2020	02/29/2024	02/29/2024
Contract Detail	Walgreens Central Fill #21394	2601 Hughes Road	Suite 103	Liberty	MO	64068	01/12/2023	04/01/2023		04/01/2023
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/06/2023	07/01/2023		07/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	04/09/2025	07/01/2025		04/09/2025

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH07440A	Active	BPS-H80-001447	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.	DOUGLAS COUNTY PUBLIC HEALTH	504 W. Broadway Ave.	AVA	MO
CH07440B	Active	BPS-H80-003085	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.	DOUGLAS COUNTY PUBLIC HLTH SRV. GROUP	87 Elm Street	Gainesville	MO
CH07440E	Active	BPS-H80-005201	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.	MISSOURI OZARKS COMMUNITY HEALTH	804 N HIGHWAY 5	MANSFIELD	MO
CH07440F	Active	BPS-H80-012330	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.	Missouri Ozarks Community Health	904 Zimmerman	Cabool	MO
CH07440G	Active	BPS-H80-015372	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.	Missouri Ozarks Community Health	1604 C North Main Street	Mountain Grove	MO
CH07440H	Active	BPS-H80-018980	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.	Missouri Ozarks Community Health-Houston	1340 South Sam Houston Blvd.	Houston	MO
CH07440J	Active	BPS-H80-028270	DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.	Missouri Ozarks Community Health Licking Medical	135 College Ave	Licking	MO

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH07440A	SUPER D DRUGS ACQUISITION CO.	AVA DRUG #15726, POWERED BY WALGREENS	124 W WASHINGTON AVE	AVA	MO	65608	07/01/2015
CH07440A	SUPER D DRUGS ACQUISITION CO.	MANSFIELD DRUG #15731	POWERED BY WALGREENS 101 N BUSINESS HWY 60	MANSFIELD	MO	65704	07/01/2015
CH07440A	SUPER D DRUGS ACQUISITION CO.	SEYMOUR PHARMACY #15732	POWERED BY WALGREENS 214 S. MAIN STREET	SEYMOUR	MO	65746	07/01/2015
CH07440G	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2018
CH07440G	WAL-MART PHARMACY 10-0015	1310 PREACHER ROE BLVD		WEST PLAINS	MO	65775	01/01/2018
CH07440G	WAL-MART PHARMACY 10-0056	1309 NW 12TH AVE		AVA	MO	65608	01/01/2018
CH07440G	WAL-MART PHARMACY 10-0088	2100 N MAIN		MOUNTAIN GROVE	MO	65711	01/01/2018
CH07440G	WAL-MART PHARMACY 10-0166	1433 SOUTH SAM HOUSTON BLVD.		HOUSTON	MO	65483	01/01/2018
CH07440G	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2018
CH07440A	WALGREEN CO.	FORBES PHARMACY #15722, POWERED BY WALGR	100 NORTH GRAND	HOUSTON	MO	65483	01/01/2020	02/29/2024
CH07440A	Walgreens Central Fill #21394	2601 Hughes Road	Suite 103	Liberty	MO	64068	04/01/2023
CH07440A	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CH07440A	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	07/01/2025
CH07440G	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	07/01/2025

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/30/2024 10:27:25 AM	2/25/2025 3:15:19 PM	2/25/2025 3:15 PM
Contacts	Authorizing Official	Update	AO Change Request	Shryack, Tim R CEO Douglas County Public Health Services Group, Inc 4176834831-110	Gann, Randall L CEO Missouri Ozarks Community Health 4176835739	2/24/2025 1:56 PM
Details	Last Recertification Date	Update	Recertification	2/1/2023 9:56:29 AM	1/30/2024 10:27:25 AM	1/30/2024 10:27 AM
Details	Last Recertification Date	Update	Recertification	2/8/2022 11:18:49 AM	2/1/2023 9:56:29 AM	2/1/2023 9:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/6/2022 9:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		605408509	4/6/2022 9:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	4/6/2022 9:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1326158957	4/6/2022 9:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	4/6/2022 9:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	605408509 (MO)		2/8/2022 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/8/2022 11:18 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		505408500	2/8/2022 11:18 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	2/8/2022 11:18 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1326158957 (MO)		2/8/2022 11:18 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1912904145	2/8/2022 11:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	2/8/2022 11:18 AM
Details	Last Recertification Date	Update	Recertification	2/10/2021 11:07:04 AM	2/8/2022 11:18:49 AM	2/8/2022 11:18 AM
Contacts	Primary Contact	Update	Profile Change Request	Heinlein, Jennifer COO Douglas County Public Health Services Group, INc. 4176834831-111	Heinlein, Jennifer COO Douglas County Public Health Services Group, INc. 4176835739-1111	1/31/2022 12:11 PM
Addresses	Billing Address	Insert	Recertification		Missouri Ozarks Community Health PO Box 1359 Ava, MO 65608	2/10/2021 11:07 AM
Details	Last Recertification Date	Update	Recertification	2/5/2020 10:29:27 AM	2/10/2021 11:07:04 AM	2/10/2021 11:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/13/2020 2:44 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		605408509	11/13/2020 2:44 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	11/13/2020 2:44 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1326158957	11/13/2020 2:44 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	11/13/2020 2:44 PM
Addresses	Shipping Address	Delete	Change Request	MOCH PHARMACY 504 NW 10TH AVENUE AVA, MO 65608		6/4/2020 3:56 PM
Addresses	Shipping Address	Insert	Change Request		MOCH PHARMACY 504 W. Broadway Ave. AVA, MO 65608	6/4/2020 3:56 PM
Addresses	Main Address	Update	Change Request	504 NW 10TH AVE AVA, MO 65608-1359	504 W. Broadway Ave. AVA, MO 65608-1359	6/4/2020 3:56 PM
Details	Last Recertification Date	Update	Recertification	2/4/2019 12:11:36 PM	2/5/2020 10:29:27 AM	2/5/2020 10:29 AM
Contacts	Primary Contact	Update	Recertification	HEINLEIN, JENNIFER EXECUTIVE ASSISTANT 4176834831	Heinlein, Jennifer COO Douglas County Public Health Services Group, INc. 4176834831-111	2/4/2019 12:11 PM
Details	Last Recertification Date	Update	Recertification	2/28/2018 9:43:54 AM	2/4/2019 12:11:36 PM	2/4/2019 12:11 PM
Details	Last Recertification Date	Update	Recertification	2/1/2017 12:00:00 AM	2/28/2018 9:43:54 AM	2/28/2018 9:43 AM
Contacts	Authorizing Official	Update	AO Change Request	Shryack, Tim CEO 4176834831	Shryack, Tim R CEO Douglas County Public Health Services Group, Inc 4176834831-110	10/4/2017 2:50 PM
Addresses	Main Address	Insert			504 NW 10TH AVE AVA, MO 65608-1359	2/1/2017 11:31 AM
Contacts	Primary Contact	Insert			HEINLEIN, JENNIFER EXECUTIVE ASSISTANT 4176834831	2/1/2017 11:31 AM
Contacts	Authorizing Official	Update		SIMS, RICHARD CEO 4176834831	Shryack, Tim CEO 4176834831	2/1/2017 11:31 AM
Details	Last Recertification Date	Update		2/23/2016 12:00:00 AM	2/1/2017 12:00:00 AM	2/1/2017 11:31 AM
Details	Last Recertification Date	Update		2/10/2015 12:00:00 AM	2/23/2016 12:00:00 AM	2/23/2016 4:49 PM
Details	Last Recertification Date	Update		3/17/2014 12:00:00 AM	2/10/2015 12:00:00 AM	2/10/2015 3:32 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/17/2014 12:00:00 AM	3/17/2014 12:09 PM
Details	Entity Subname	Update		DOUGLAS COUNTY CHC CLINIC	DOUGLAS COUNTY PUBLIC HEALTH	3/17/2014 12:09 PM
Contacts	Authorizing Official	Insert			SIMS, RICHARD CEO 4176834831	2/27/2013 11:32 AM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	2/27/2013 11:32 AM
Addresses	Shipping Address	Insert			MOCH PHARMACY 504 NW 10TH AVENUE AVA, MO 65608	1/11/2010 3:45 PM
Details	Last Recertification Date	Insert				1/11/2010 3:45 PM
Details	Grant Number	Insert			H80CS00457	1/11/2010 3:45 PM
Details	340B ID	Insert			CH07440A	1/11/2010 3:45 PM
Details	Is Authorizing Official EHB Data	Insert				1/11/2010 3:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/11/2010 3:45 PM
Details	Medicare Provider Number	Insert				1/11/2010 3:45 PM
Details	Entity Name	Insert			DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.	1/11/2010 3:45 PM
Details	Program Code	Insert			CH	1/11/2010 3:45 PM
Details	Entity Subname	Insert			DOUGLAS COUNTY CHC CLINIC	1/11/2010 3:45 PM
Dates	Participating Approval Date	Insert			3/25/2004 12:00:00 AM	1/11/2010 3:45 PM
Details	State	Insert			Active	1/11/2010 3:45 PM
Dates	Registration Date	Insert			4/1/2004 12:00:00 AM	1/11/2010 3:45 PM
Dates	Signed By Date	Insert				1/11/2010 3:45 PM
Dates	Start Date	Insert			4/1/2004 12:00:00 AM	1/11/2010 3:45 PM
Terminations	Termination Comments	Insert				1/11/2010 3:45 PM
Terminations	Termination Date	Insert				1/11/2010 3:45 PM
Terminations	Termination Effective Date	Insert				1/11/2010 3:45 PM
Terminations	Termination Reason	Insert				1/11/2010 3:45 PM
Details	Comments Public	Insert			10/10/08 ADDED MEDICAID #S; 10/7/2008 ADDED IN HOUSE PHARMACY AS SHIPPING ADDR.	1/11/2010 3:45 PM

340B Drug Pricing Program Database