Covered Entity Details

CH07213U NORTHWEST HEALTH SERVICES, INC. (Active) - information as of 6/11/2025 7:18:53 PM

Main Details

Name

NORTHWEST HEALTH SERVICES, INC.

Subdivision Name

SOUTH SIDE HEALTH CENTER

Type

HRSA-Funded Health Center

Site ID

BPS-H80-002442

340B ID

CH07213U

Grant Number

H80CS00671

Additional Details

Current Program Status

Active

Registration Date

4/1/2005

Participating Start Date

4/1/2005

Participating Approval Date

1/27/2005

Last Recertification Date

2/19/2025

Contacts

Authorizing Official

Northwest Health Services
Matt Younger, CEO
(816) 307-5303

Primary Contact

Northwest Health Services
Miranda Phillips, Director of Pharmacy
(816) 385-5997

Addresses

Street Address

5001 Lake Ave
Saint Joseph, MO 64504-1170

Billing Address
Same as Street Address

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

Comments

Comment	Last Updated On
NEW SITE 04/01/2005	04/01/2005

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
KS	30003899230002	1194846550
MO	509384202	1194846550

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
Contract Detail	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	03/01/2018	04/01/2018			03/01/2018
Contract Detail	STEVENSON FAMILY PHARMACY	6201 KING HILL AVE		SAINT JOSEPH	MO	64504	09/01/2005	09/01/2005			03/28/2013

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH072130	Active	BPS-H80-002392	NORTHWEST HEALTH SERVICES, INC.	FAMILY MEDICINE ASSOCIATES	2303 Village Dr	Saint Joseph	MO
CH07213A	Active	BPS-H80-005680	NORTHWEST HEALTH SERVICES, INC.	King City Clinic	305 Rhode Island St	King City	MO
CH07213AA	Active	BPS-H80-013703	NORTHWEST HEALTH SERVICES, INC.	Northwest Family Dental and Behavioral Health	3608 FARAON ST	SAINT JOSEPH	MO
CH07213AB	Active	BPS-H80-021517	NORTHWEST HEALTH SERVICES, INC.	Northwest Health Services Downtown Health Center	503 S 6th St	Saint Joseph	MO
CH07213AC	Active	BPS-H80-030147	NORTHWEST HEALTH SERVICES, INC.	Gower Family Medicine	313 S US Highway 169	Gower	MO
CH07213AD	Active	BPS-H80-024852	NORTHWEST HEALTH SERVICES INC	Northwest Health Mobile Unit	2303 Village Dr	Saint Joseph	MO
CH07213AE	Active	BPS-H80-035777	NORTHWEST HEALTH SERVICES INC	Northwest Health Services - Chillicothe	300 W Business 36	Chillicothe	MO
CH07213B	Active	BPS-H80-003069	NORTHWEST HEALTH SERVICES, INC.	SAVANNAH MEDICAL CLINIC	803 HIGHWAY 71 WEST	SAVANNAH	MO
CH07213E	Active	BPS-H80-006325	NORTHWEST HEALTH SERVICES, INC.	BRAYMER CLINIC	109 MAIN STREET	BRAYMER	MO
CH07213F	Active	BPS-H80-002437	NORTHWEST HEALTH SERVICES, INC.	HAMILTON MEDICAL CLINIC	101 CROSS STREET	HAMILTON	MO
CH07213K	Active	BPS-H80-009170	NORTHWEST HEALTH SERVICES, INC.	Mound City Clinic	1303 State St	Mound City	MO
CH07213Q	Active	BPS-H80-006309	NORTHWEST HEALTH SERVICES, INC.	CAINSVILLE MEDICAL CLINIC	707 VICTORY LANE	CAINSVILLE	MO
CH07213T	Active	BPS-H80-034418	NORTHWEST HEALTH SERVICES, INC.	NORTH END HEALTH CENTER	1000 5th Avenue	Saint Joseph	MO
CH07213U	Active	BPS-H80-002442	NORTHWEST HEALTH SERVICES, INC.	SOUTH SIDE HEALTH CENTER	5001 Lake Ave	Saint Joseph	MO
CH07213W	Terminated	BPS-H80-007691	NORTHWEST HEALTH SERVICES, INC.	HOME Unit	904 south 10th street STE A	St Joseph	MO
CH07213Y	Terminated	BPS-H80-010931	NORTHWEST HEALTH SERVICES, INC.	McCoy and Samples Dental Clinic - Hamilton	500 1/2 S Davis St	Hamilton	MO
CH07213Z	Terminated	BPS-H80-007618	NORTHWEST HEALTH SERVICES, INC.	McCoy & Samples Dental Clinic	850 Fairway Dr	Chillicothe	MO

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH072130	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/01/2018
CH072130	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/01/2018
CH072130	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/01/2018
CH072130	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/01/2018
CH072130	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/01/2018
CH072130	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/01/2018
CH072130	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/01/2024
CH072130	BENDERS PRESCRIPTION SHOP	3829 FREDERICK AVENUE		SAINT JOSEPH	MO	64506	04/01/2015	04/11/2019
CH072130	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	10/01/2018	10/01/2019
CH072130	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	10/01/2018	10/01/2019
CH072130	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/01/2020
CH072130	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/01/2020
CH072130	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/01/2020
CH072130	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/01/2020
CH072130	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/01/2020
CH072130	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/01/2020
CH072130	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/01/2020
CH072130	CAREMARK PUERTO RICO SPECIALTY PHARMACY,	CAREMARK PUERTO RICO SPECIALTY PHARMACY	6020 AVE ROBERTO SANCHEZ VILELLA	CAROLINA	PR	00982	10/01/2020	08/17/2022
CH072130	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/01/2020
CH072130	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/01/2020
CH072130	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/01/2020
CH072130	COSENTINO GROUP INC	PRICE CHOPPER PHARMACY #416	2219 N BELT HWY	SAINT JOSEPH	MO	64506-2205	01/01/2017
CH072130	COUNTRYSIDE PHARMACY	402 E PRICE AVE	P.O. BOX 147	SAVANNAH	MO	64485-1742	07/27/2011	03/21/2025
CH072130	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/01/2021
CH072130	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/01/2021
CH072130	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/01/2020
CH072130	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/01/2024
CH072130	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/01/2020	04/08/2024
CH072130	GENOA HEALTHCARE LLC	724 NORTH 22ND STREET		SAINT JOSEPH	MO	64506	07/01/2024
CH072130	GENOA HEALTHCARE LLC	902 EDMOND ST STE 202		SAINT JOSEPH	MO	64501	07/01/2024
CH072130	HY-VEE INC	DBA HY-VEE PHARMACY (1552)	201 N BELT HIGHWAY	ST JOSEPH	MO	64506	10/01/2017	08/31/2024
CH072130	Hy-Vee Pharmacy Fulfillment Center #4016	Hy-Vee Inc	4707 Fleur Dr	Des Moines	IA	50321	07/01/2021	08/31/2024
CH072130	Hy-Vee Pharmacy Fullfillment Center #4016	Hy-Vee Inc	4704 Fleur Dr	Des Moines	IA	50321	10/01/2017	06/07/2021
CH072130	K MART PHARMACY 4026	2901 5 N BELT HWY		ST JOSEPH	MO	64506	04/01/2015	11/05/2018
CH072130	MISSOURI CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05645	930 N BELT HWY	SAINT JOSEPH	MO	64506	10/01/2016
CH072130	MISSOURI CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY# 8236	1301 S BELT HWY	SAINT JOSEPH	MO	64507	04/01/2019
CH072130	MISSOURI CVS PHARMACY, L.L.C.	CVS/PHARMACY # 10506	3320 NORTH BELT HIGHWAY	SAINT JOSEPH	MO	64506	04/01/2019
CH072130	MISSOURI CVS PHARMACY, L.L.C.	CVS PHARMACY # 17093	5201 N BELT HWY STE H	SAINT JOSEPH	MO	64506	10/01/2019
CH072130	MISSOURI CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08577	4400 NW BARRY ROAD	KANSAS CITY	MO	64154	10/01/2020
CH072130	MISSOURI CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 10152	1501 E. OHIO ST.	CLINTON	MO	64735	10/01/2020
CH072130	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/01/2018	06/01/2021
CH072130	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/06/2022	04/04/2024
CH072130	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/01/2018
CH072130	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	07/01/2024
CH072130	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/01/2018	04/04/2024
CH072130	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	10/01/2018	04/04/2024
CH072130	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/01/2024
CH072130	POIRIER PHARMACY INC	POIRIER PHARMACY	102 SO 5TH STREET P.O. BOX 128	SAVANNAH	MO	64485	06/16/2011	12/09/2015
CH072130	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/01/2020
CH072130	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/01/2020
CH072130	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	10/01/2020
CH072130	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/01/2020
CH072130	RIVERSIDE PHARMACY ASSOCIATES, LLC	DBA APEX SPECIALTY PHARMACY	616 NW PLATTE VALLEY DR	RIVERSIDE	MO	64150-9798	04/01/2019	04/08/2024
CH072130	ROGERS PHARMACY	3705 N BELT HWY		SAINT JOSEPH	MO	64506	04/01/2015
CH072130	ROGERS PHARMACY	607 STATE ST		MOUND CITY	MO	64470-1146	10/01/2015
CH072130	ROGERS PHARMACY	411 MAIN ST		TARKIO	MO	64491	10/01/2015
CH072130	SAVANNAH FAMILY PHARMACY	205 S. 71 HWY		SAVANNAH	MO	64485	01/05/2012	03/28/2018
CH07213B	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH072130	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	03/07/2018
CH07213A	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213AA	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213AB	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213E	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213F	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213K	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213Q	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213T	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213U	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018
CH07213W	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018	04/01/2019
CH07213Y	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018	04/01/2022
CH07213Z	SAVANNAH FAMILY PHARMACY	205 S US HIGHWAY 71		SAVANNAH	MO	64485	04/01/2018	04/01/2022
CH072130	SHOPKO PHARMACY #2710	212 N MAIN ST		GALLATIN	MO	64640	07/01/2016	06/01/2017
CH072130	Stevenson Family Pharmacy	6201 King Hill		St. Joseph	MO	64504	09/12/2011
CH07213U	STEVENSON FAMILY PHARMACY	6201 KING HILL AVE		SAINT JOSEPH	MO	64504	09/01/2005
CH07213T	THE APOTHECARY	1517 ST JOSEPH AVENUE		ST JOSEPH	MO	64505	07/01/2005
CH072130	The Apothecary Pharmacy	1517 St. Joseph Ave		St. Joseph	MO	64504	09/12/2011	12/21/2018
CH072130	THE DRUG STORE	KCJSE INC	610 N WALNUT ST	CAMERON	MO	64429-1831	06/20/2011
CH072130	THE PHARMACY AT APPLE MARKET NORTH	WHEEL'S PHARMACY,LLC	903 N 36TH ST	SAINT JOSEPH	MO	64506-2971	10/01/2015	12/01/2016
CH072130	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2017
CH072130	WAL-MART PHARMACY 10-0109	2000 N WALNUT		CAMERON	MO	64429	04/01/2015
CH072130	WAL-MART PHARMACY 10-0135	1000 GRAVES STREET		CHILLICOTHE	MO	64601	04/01/2015
CH072130	WAL-MART PHARMACY 10-0189	2206 N BALTIMORE		KIRKSVILLE	MO	63501	09/21/2012	09/18/2015
CH072130	WAL-MART PHARMACY 10-0325	908 S. WALTON WAY		RICHMOND	MO	64085	04/01/2015
CH072130	WAL-MART PHARMACY 10-0342	701 HOPI DR.		HIAWATHA	KS	66434	04/01/2015
CH072130	WAL-MART PHARMACY 10-0560	4201 N BELT HWY		ST JOSEPH	MO	64506	04/01/2015
CH072130	WAL-MART PHARMACY 10-0801	1605 SOUTH MAIN STREET		MARYVILLE	MO	64468	04/01/2015
CH072130	WAL-MART PHARMACY 10-0834	810 SOUTH 37TH STREET		BETHANY	MO	64424	04/01/2015
CH072130	WAL-MART PHARMACY 10-2994	3022 SOUTH BELT HIGHWAY		ST JOSEPH (S)	MO	64503	04/01/2015
CH072130	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2017
CH072130	WALGREEN CO	DBA: WALGREENS #10725	4022 N BELT HIGHWAY	SAINT JOSEPH	MO	64506	07/01/2018
CH072130	WALGREEN CO.	DBA: WALGREENS # 04466	3645 FREDERICK AVENUE	ST JOSEPH	MO	64506	07/01/2018
CH072130	WALGREEN CO.	DBA: WALGREENS # 07551	2620 S BELT HIGHWAY	ST JOSEPH	MO	64503-1646	07/01/2018
CH072130	WALGREEN CO.	DBA: WALGREENS #12821	1114 S MAIN ST	MARYVILLE	MO	64468	07/01/2018	11/11/2020
CH072130	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16072	3537 BROADWAY BLVD	KANSAS CITY	MO	64111	10/01/2018
CH072130	WALGREEN CO.	COMMUNITY, A WALGREENS PHARMACY #16518	6407 W 119TH ST STE G5	OVERLAND PARK	KS	66209	10/01/2018
CH07213A	WALGREEN CO.	COMMUNITY, A WALGREENS PHARMACY #16518	6407 W 119TH ST STE G5	OVERLAND PARK	KS	66209	10/01/2018
CH07213A	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16072	3537 BROADWAY BLVD	KANSAS CITY	MO	64111	10/01/2018
CH072130	Walgreens Central Fill #21394	2601 Hughes Road	Suite 103	Liberty	MO	64068	10/01/2023
CH072130	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/01/2018	02/26/2021
CH072130	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/01/2024
CH072130	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/01/2024
CH072130	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/01/2024
CH072130	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	07/01/2018
CH072130	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CH072130	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024
CH072130	WHEEL'S PHARMACY	DBA WHEEL'S MARKET PHARMACY	3002 PEAR ST	SAINT JOSEPH	MO	64503	10/01/2015	04/03/2023

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/30/2024 5:02:15 PM	2/19/2025 5:11:52 PM	2/19/2025 5:11 PM
Details	Last Recertification Date	Update	Recertification	2/14/2023 10:05:07 AM	1/30/2024 5:02:15 PM	1/30/2024 5:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/14/2023 10:05 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		30003899230002	2/14/2023 10:05 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KS	2/14/2023 10:05 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100288780G (KS)		2/14/2023 10:05 AM
Details	Last Recertification Date	Update	Recertification	2/22/2022 10:28:16 AM	2/14/2023 10:05:07 AM	2/14/2023 10:05 AM
Details	Last Recertification Date	Update	Recertification	2/10/2021 2:39:02 PM	2/22/2022 10:28:16 AM	2/22/2022 10:28 AM
Contacts	Authorizing Official	Update	Profile Change Request	Younger, Matt CEO Northwest Health Services 8162718201	Younger, Matt CEO Northwest Health Services 8163075303	6/3/2021 5:21 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1194846550	2/10/2021 2:39 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	2/10/2021 2:39 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1194846550	2/10/2021 2:39 PM
Medicaid Billing	NPI: State	Insert	Recertification		KS	2/10/2021 2:39 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1194846550 ( )		2/10/2021 2:39 PM
Details	Last Recertification Date	Update	Recertification	1/28/2020 1:23:21 PM	2/10/2021 2:39:02 PM	2/10/2021 2:39 PM
Contacts	Authorizing Official	Update	AO Change Request	Lamb, Deanna CEO Northwest Health Services 8162718201	Younger, Matt CEO Northwest Health Services 8162718201	10/14/2020 11:52 AM
Details	Last Recertification Date	Update	Recertification	1/28/2019 5:13:54 PM	1/28/2020 1:23:21 PM	1/28/2020 1:23 PM
Contacts	Primary Contact	Update	Recertification	Harris, Tina Director of Finance Northwest Health Services 8162718213	Phillips, Miranda Director of Pharmacy Northwest Health Services 8163855997	1/28/2019 5:13 PM
Details	Last Recertification Date	Update	Recertification	2/12/2018 10:42:37 AM	1/28/2019 5:13:54 PM	1/28/2019 5:13 PM
Details	Last Recertification Date	Update	Recertification	2/13/2017 12:00:00 AM	2/12/2018 10:42:37 AM	2/12/2018 10:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/8/2018 2:48 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100288780G	1/8/2018 2:48 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	1/8/2018 2:48 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/8/2018 2:48 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		509384202	1/8/2018 2:48 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	1/8/2018 2:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1194846550	1/8/2018 2:48 PM
Contacts	Primary Contact	Update	Change Request	Lamb, Deanna CEO Northwest Health Services 8162718201	Harris, Tina Director of Finance Northwest Health Services 8162718213	1/8/2018 2:48 PM
Contacts	Authorizing Official	Update		Lamb, Deanna CEO 8162718201	Lamb, Deanna CEO Northwest Health Services 8162718201	1/2/2018 12:18 PM
Contacts	Primary Contact	Update		Lamb, Deanna CEO 8162718201	Lamb, Deanna CEO Northwest Health Services 8162718201	1/2/2018 12:18 PM
Contacts	Authorizing Official	Insert			Lamb, Deanna CEO 8162718201	7/13/2017 2:51 PM
Contacts	Primary Contact	Update		Wright, Nichole COO 8162718234	Lamb, Deanna CEO 8162718201	7/13/2017 2:51 PM
Addresses	Main Address	Insert			5001 Lake Ave Saint Joseph, MO 64504-1170	2/13/2017 11:43 AM
Details	Last Recertification Date	Update		2/26/2016 12:00:00 AM	2/13/2017 12:00:00 AM	2/13/2017 11:43 AM
Details	Last Recertification Date	Update		1/28/2015 12:00:00 AM	2/26/2016 12:00:00 AM	2/26/2016 11:22 AM
Contacts	Primary Contact	Update		Thompson, Laurie Director PIRM 8169011499	Wright, Nichole COO 8162718234	5/29/2015 2:52 PM
Details	Last Recertification Date	Update		3/17/2014 12:00:00 AM	1/28/2015 12:00:00 AM	1/28/2015 2:53 PM
Contacts	Primary Contact	Insert			Thompson, Laurie Director PIRM 8169011499	1/12/2015 5:25 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	3/17/2014 12:00:00 AM	3/17/2014 12:24 PM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	2/25/2013 10:20 AM
Dates	Participating Approval Date	Update		1/27/2005 2:05:59 PM	1/27/2005 12:00:00 AM	12/5/2012 9:09 AM
Details	Last Recertification Date	Insert				4/1/2005 12:00 AM
Details	Grant Number	Insert			H80CS00671	4/1/2005 12:00 AM
Details	340B ID	Insert			CH07213U	4/1/2005 12:00 AM
Details	Is Authorizing Official EHB Data	Insert				4/1/2005 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/1/2005 12:00 AM
Details	Medicare Provider Number	Insert				4/1/2005 12:00 AM
Details	Entity Name	Insert			NORTHWEST HEALTH SERVICES, INC.	4/1/2005 12:00 AM
Details	Program Code	Insert			CH	4/1/2005 12:00 AM
Details	Entity Subname	Insert			SOUTH SIDE HEALTH CENTER	4/1/2005 12:00 AM
Dates	Participating Approval Date	Insert			1/27/2005 2:05:59 PM	4/1/2005 12:00 AM
Details	State	Insert			Active	4/1/2005 12:00 AM
Dates	Registration Date	Insert			4/1/2005 12:00:00 AM	4/1/2005 12:00 AM
Dates	Signed By Date	Insert				4/1/2005 12:00 AM
Dates	Start Date	Insert			4/1/2005 12:00:00 AM	4/1/2005 12:00 AM
Terminations	Termination Comments	Insert				4/1/2005 12:00 AM
Terminations	Termination Date	Insert				4/1/2005 12:00 AM
Terminations	Termination Effective Date	Insert				4/1/2005 12:00 AM
Terminations	Termination Reason	Insert				4/1/2005 12:00 AM
Details	Comments Public	Insert			NEW SITE 04/01/2005	4/1/2005 12:00 AM

340B Drug Pricing Program Database