Covered Entity Details

DSH260017 PHELPS COUNTY REGIONAL MEDICAL CNTR (Active) - information as of 5/25/2025 1:15:57 AM

Main Details

Name

PHELPS COUNTY REGIONAL MEDICAL CNTR

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260017

Medicare Provider Number

260017

Additional Details

Current Program Status

Active

Registration Date

2/25/2021

Participating Start Date

3/2/2021

Participating Approval Date

3/2/2021

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

Phelps County Regional Medical Center
Jana Cook, Chief Financial Officer
(573) 458-7916

Primary Contact

Phelps County Regional Medical Center
KREIG Leland MOORE, DIRECTOR OF PHARMACY
(573) 458-7892

Addresses

Street Address

1000 WEST 10TH STREET
ROLLA, MO 65401

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 10/1/2009, terminated 10/1/2020. Reinstated 3/2/2021.	03/02/2021
10/1/09 REINSTATED ORIG PART FROM 9/9/05 TO 6/30/07, NOT ELIG FROM 7/1/07 TO 9/30/09	09/23/2009

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	010419109	1891766051

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	6 TURTLES, LLC	DBA DR. TIM'S PHARMACY	125 N JEFFERSON ST	SAINT JAMES	MO	65559	01/11/2024	04/01/2024		04/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/11/2024	04/01/2024		04/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/11/2024	04/01/2024		04/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/11/2024	04/01/2024		04/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/11/2024	04/01/2024		04/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/11/2024	04/01/2024		04/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/11/2024	04/01/2024		04/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	01/13/2025	04/01/2025		04/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	01/13/2025	04/01/2025		04/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	01/13/2025	04/01/2025		04/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	01/13/2025	04/01/2025		04/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	01/13/2025	04/01/2025		04/01/2025
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	05/18/2023	05/24/2023		05/24/2023
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	05/18/2023	05/24/2023		05/24/2023
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	01/13/2025	04/01/2025		04/01/2025
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	01/11/2024	04/01/2024		04/01/2024
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	01/11/2024	04/01/2024		04/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	01/11/2024	04/01/2024		04/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	01/11/2024	04/01/2024		04/01/2024
Contract Detail	FOREST CITY MEDICAL CTR PHARM	1000 B N JEFFERSON		ST JAMES	MO	65559	01/11/2024	04/01/2024	05/31/2025	05/22/2025
Contract Detail	HILLCREST DRUG INC	1100 B SOUTH BISHOP		ROLLA	MO	65401-4418	04/15/2013	07/01/2013	11/16/2018	12/18/2018
Contract Detail	MEDLEY PHARMACY	733 W SPRINGFIELD AVE		GERALD	MO	63037	05/18/2023	05/24/2023		05/24/2023
Contract Detail	MEDLEY PHARMACY	601 E HWY 28	PO BOX 528	OWENSVILLE	MO	65066	05/18/2023	05/24/2023		05/24/2023
Contract Detail	MISSOURI CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #10280	500 N BISHOP AVENUE	ROLLA	MO	65401-2989	05/18/2023	05/24/2023		05/24/2023
Contract Detail	MOSER PHARMACY	900 S MAIN ST		SALEM	MO	65560-1639	01/11/2024	04/01/2024		04/01/2024
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	02/01/2013	04/01/2013	10/01/2020	10/01/2020
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	03/04/2021	03/04/2021		03/04/2021
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF PHILADE	LLC DBA ONCO360	1553 CHESTER PIKE SUITE 206	CRUM LYNNE	PA	19022	07/12/2013	10/01/2013	10/13/2016	10/27/2016
Contract Detail	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	10/16/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	10/16/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/16/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/16/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	10/16/2023	01/01/2024		01/01/2024
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/16/2023	01/01/2024		01/01/2024
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	05/18/2023	05/24/2023		05/24/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	05/18/2023	05/24/2023		05/24/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	05/18/2023	05/24/2023		05/24/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	05/18/2023	05/24/2023		05/24/2023
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	01/13/2025	04/01/2025		04/01/2025
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	01/13/2025	04/01/2025		04/01/2025
Contract Detail	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	01/13/2025	04/01/2025		04/01/2025
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	07/12/2013	10/01/2013	05/06/2020	05/15/2020
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	10/27/2016	01/01/2017	10/01/2020	10/01/2020
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	03/04/2021	03/04/2021		03/04/2021
Contract Detail	SINKS PHARMACY	1375 E 10TH ST STE B		ROLLA	MO	65401-3591	04/10/2013	07/01/2013	10/01/2020	10/01/2020
Contract Detail	SINKS PHARMACY	606 HIGHWAY 63 S	P.O. BOX 606	VIENNA	MO	65582-8101	04/10/2013	07/01/2013	10/01/2020	10/01/2020
Contract Detail	SINKS PHARMACY	1000 GW LN STE 105		WAYNESVILLE	MO	65583	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY	153 E SPRINGFIELD RD		SULLIVAN	MO	63080	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY	1435 N MAIN ST		SAINT CLAIR	MO	63077	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY	1375 E 10TH ST STE B		ROLLA	MO	65401	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY	124 N OLD HIGHWAY 66		BOURBON	MO	65441	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY	1204 E HIGHWAY 32		SALEM	MO	65560	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY	606 HIGHWAY 63 S		VIENNA	MO	65582	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY	2322 HIGHWAY 17		IBERIA	MO	65486	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY #100	206 S ALVARADO AVE STE D	PO BOX 934	BELLE	MO	65013	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY SELECT, LLC	1100 S BISHOP AVE STE B		ROLLA	MO	65401	05/18/2023	05/24/2023		05/24/2023
Contract Detail	SINKS PHARMACY SOUTH	1100B S BISHOP AVE		ROLLA	MO	65401-4418	04/10/2013	07/01/2013	10/01/2020	10/01/2020
Contract Detail	SINKS PHARMACY SOUTH	1100B S BISHOP AVE		ROLLA	MO	65401-4418	05/18/2023	05/24/2023		05/24/2023
Contract Detail	STEELVILLE DRUG	503 W MAIN ST		STEELVILLE	MO	65565	05/18/2023	05/24/2023		05/24/2023
Contract Detail	THE TOWNE PHARMACY	200 N FRANKLIN ST		CUBA	MO	65453	05/18/2023	05/24/2023		05/24/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/16/2017	04/01/2017	10/01/2020	10/01/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	05/18/2023	05/24/2023		05/24/2023
Contract Detail	WAL-MART PHARMACY 10-0021	185 ST. ROBERT BLVD.		SAINT ROBERT	MO	65584	05/18/2023	05/24/2023		05/24/2023
Contract Detail	WAL-MART PHARMACY 10-0027	1101 HWY 32 WEST		SALEM	MO	65560	05/18/2023	05/24/2023		05/24/2023
Contract Detail	WAL-MART PHARMACY 10-0101	500 S BISHOP		ROLLA	MO	65401	02/01/2013	04/01/2013	10/01/2020	10/01/2020
Contract Detail	WAL-MART PHARMACY 10-0101	500 S BISHOP		ROLLA	MO	65401	05/18/2023	05/24/2023		05/24/2023
Contract Detail	WAL-MART PHARMACY 10-0895	100 OZARK DRIVE		CUBA	MO	65453	05/18/2023	05/24/2023		05/24/2023
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/16/2017	04/01/2017	10/01/2020	10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	05/18/2023	05/24/2023		05/24/2023
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21346	3527 CHOUTEAU AVE	SAINT LOUIS	MO	63103	01/11/2024	04/01/2024		04/01/2024
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16534	1500 E SUNSHINE ST STE 148	SPRINGFIELD	MO	65804	01/11/2024	04/01/2024		04/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12307	120 S BISHOP AVE	ROLLA	MO	65401-4215	01/11/2024	04/01/2024		04/01/2024
Contract Detail	Walgreens Central Fill #21394	2601 Hughes Road	Suite 103	Liberty	MO	64068	01/11/2024	04/01/2024		04/01/2024
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	05/18/2023	05/24/2023		05/24/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/16/2023	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH260017A	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - ONCOLOGY SERVICES	1060 West 10th Street	Rolla	MO	Active
DSH260017AA	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Pain Clinic (Suite 330)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AB	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Pediatrics (Suite 300)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AC	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Waynesville Medical Plaza Family Medicine (Suite 200)	1000 GW Ln.	Waynesville	MO	Active
DSH260017AD	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Waynesville Medical Plaza Pediatrics (Suite 200)	1000 GW Ln.	Waynesville	MO	Active
DSH260017AE	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Waynesville Medical Plaza Specialty (Suite 250)	1000 GW Ln.	Waynesville	MO	Terminated
DSH260017AF	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Delbert Day Cancer Institute - Radiation Oncology (Ground Floor)	1060 W 10th Street	Rolla	MO	Active
DSH260017AG	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Delbert Day Cancer Institute - Medical Oncology	1060 West 10th Street	Rolla	MO	Active
DSH260017AH	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza Urology	1000 GW Ln.	Waynesville	MO	Active
DSH260017AJ	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza Nephrology	1000 GW Ln.	Waynesville	MO	Active
DSH260017AK	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza Pulmonology	1000 GW Ln.	Waynesville	MO	Active
DSH260017AL	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza Orthopedics	1000 GW Ln.	Waynesville	MO	Active
DSH260017AM	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS COUNTY REGIONAL MED. CENTER - Phelps Health Waynesville Medical Plaza Podiatry	1000 GW Ln.	Waynesville	MO	Active
DSH260017AN	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza General Surgery	1000 GW Ln.	Waynesville	MO	Active
DSH260017AP	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Waynesville Medical Plaza ENT	1000 GW Ln.	Waynesville	MO	Active
DSH260017AQ	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Gerontology	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AR	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Family Medicine (Suite 380)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AS	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Podiatry (Suite 400)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017AT	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - PET	1060 W 10TH ST	ROLLA	MO	Approved
DSH260017B	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Ambulatory Surgery Center	1050 West 10th Street	Rolla	MO	Active
DSH260017C	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Bond Building - Audiology	600 BLUES LAKE PKWY	ROLLA	MO	Active
DSH260017D	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Bond Building Family Medicine	600 BLUES LAKE PKWY	ROLLA	MO	Active
DSH260017E	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Bond Building Internal Medicine	600 BLUES LAKE PKWY	ROLLA	MO	Active
DSH260017F	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Allergy	1050 West 10th Street	ROLLA	MO	Active
DSH260017G	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health ENT	1050 W 10TH ST	ROLLA	MO	Active
DSH260017H	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Urology (Suite 150)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017J	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Gastroenterology (Suite 580)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017K	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Immediate Care Clinic - Waynesville (Suite 150)	1000 GW Ln.	Waynesville	MO	Active
DSH260017L	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Salem - Podiatry	1415 West Scenic Rivers Blvd.	Salem	MO	Active
DSH260017M	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Immediate Care Clinic - Rolla	603 South Bishop Ave	Rolla	MO	Active
DSH260017N	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health Waynesville Medical Plaza - Women's Health	1000 GW Ln.	Waynesville	MO	Active
DSH260017P	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Physical Medicine and Rehabilitation (Suite 450)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017Q	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Nephrology (Suite 480)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017R	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Pulmonology (Suite 550)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017S	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Heart and Vascular Center (Suite 500)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017T	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Orthopedics (Suite 400)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017U	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Internal Medicine (Suite 350)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017V	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Phelps Health General Surgery	1060 West 10th Street	Rolla	MO	Active
DSH260017W	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health Women's Health and Maternity Services (Suite 510)	1050 W 10TH ST	ROLLA	MO	Active
DSH260017X	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health St James - Behavioral Health	1000 N JEFFERSON ST	SAINT JAMES	MO	Terminated
DSH260017Y	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health - Salem Family Medicine Clinic	1415 West Scenic Rivers Blvd.	Salem	MO	Active
DSH260017Z	Child	DSH	PHELPS COUNTY REGIONAL MEDICAL CNTR	PHELPS HEALTH - Phelps Health St James Family Medicine Clinic	1000 N JEFFERSON ST	SAINT JAMES	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/4/2023 7:59:00 AM	8/27/2024 12:57:26 PM	8/27/2024 12:57 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 10:33:39 AM	9/4/2023 7:59:00 AM	9/4/2023 7:59 AM
Details	Last Recertification Date	Update	Recertification	8/26/2021 11:21:11 AM	9/8/2022 10:33:39 AM	9/8/2022 10:33 AM
Details	Last Recertification Date	Update	Recertification		8/26/2021 11:21:11 AM	8/26/2021 11:21 AM
Details	State	Update	OPA Edit	Approved	Active	3/2/2021 1:33 PM
Dates	Start Date	Update	OPA Edit	4/1/2021 12:00:00 AM	3/2/2021 12:00:00 AM	3/2/2021 1:33 PM
Medicaid Billing	NPI: State	Update	Hospital Type Change Request		MO	3/2/2021 1:30 PM
Contacts	Signed By	Insert	Hospital Type Change Request		Cook, Jana Chief Financial Officer Phelps County Regional Medical Center 5734587916	3/2/2021 1:30 PM
Details	Last Recertification Date	Update	Hospital Type Change Request	9/2/2019 3:46:46 PM		3/2/2021 1:30 PM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request	8/27/2020 12:00:00 AM		3/2/2021 1:30 PM
Details	Entity Name	Update	Hospital Type Change Request	PHELPS HEALTH	PHELPS COUNTY REGIONAL MEDICAL CNTR	3/2/2021 1:30 PM
Dates	Participating Approval Date	Update	Hospital Type Change Request	9/23/2009 12:00:00 AM	3/2/2021 1:30:18 PM	3/2/2021 1:30 PM
Details	State	Update	Hospital Type Change Request	Terminated	Approved	3/2/2021 1:30 PM
Dates	Registration Date	Update	Hospital Type Change Request	8/29/2005 12:00:00 AM	2/25/2021 10:07:54 AM	3/2/2021 1:30 PM
Dates	Signed By Date	Update	Hospital Type Change Request	7/9/2009 12:00:00 AM	3/2/2021 11:06:19 AM	3/2/2021 1:30 PM
Dates	Start Date	Update	Hospital Type Change Request	10/1/2009 12:00:00 AM	4/1/2021 12:00:00 AM	3/2/2021 1:30 PM
Terminations	Termination Comments	Update	Hospital Type Change Request	Entering Termination today as OPIAS has been unavailable for last few days.		3/2/2021 1:30 PM
Terminations	Termination Date	Update	Hospital Type Change Request	10/1/2020 12:00:00 AM		3/2/2021 1:30 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request	9/1/2020 12:00:00 AM		3/2/2021 1:30 PM
Terminations	Termination Reason	Update	Hospital Type Change Request	DSH percentage below statutory minimum		3/2/2021 1:30 PM
Details	Comments Public	Insert	Hospital Type Change Request		Participated starting 10/1/2009, terminated 10/1/2020. Reinstated 3/2/2021.	3/2/2021 12:46 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		8/27/2020 12:00:00 AM	9/8/2020 9:13 AM
Details	State	Update	Recertification	Active	To Be Terminated	9/8/2020 9:13 AM
Terminations	Termination Comments	Update	Recertification		Entering Termination today as OPIAS has been unavailable for last few days.	9/8/2020 9:13 AM
Terminations	Termination Date	Update	Recertification		10/1/2020 12:00:00 AM	9/8/2020 9:13 AM
Terminations	Termination Effective Date	Update	Recertification		9/1/2020 12:00:00 AM	9/8/2020 9:13 AM
Terminations	Termination Reason	Update	Recertification		DSH percentage below statutory minimum	9/8/2020 9:13 AM
Details	Last Recertification Date	Update	Recertification	9/12/2018 11:21:28 AM	9/2/2019 3:46:46 PM	9/2/2019 3:46 PM
Details	Entity Name	Update	Change Request	PHELPS COUNTY REGIONAL MEDICAL CENTER	PHELPS HEALTH	1/4/2019 11:35 AM
Details	Last Recertification Date	Update	Recertification	11/7/2017 9:07:48 AM	9/12/2018 11:21:28 AM	9/12/2018 11:21 AM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/7/2017 9:07:48 AM	11/7/2017 9:07 AM
Contacts	Authorizing Official	Update		Cook, Jana Chief Financial Officer 5734587916	Cook, Jana Chief Financial Officer Phelps County Regional Medical Center 5734587916	10/9/2017 3:11 PM
Contacts	Primary Contact	Update		MOORE, KREIG DIRECTOR OF PHARMACY 5734587892	MOORE, KREIG Leland DIRECTOR OF PHARMACY Phelps County Regional Medical Center 5734587892	10/6/2017 11:50 AM
Addresses	Main Address	Insert			1000 WEST 10TH STREET ROLLA, MO 65401	7/11/2017 10:39 AM
Contacts	Primary Contact	Insert			MOORE, KREIG DIRECTOR OF PHARMACY 5734587892	7/11/2017 10:39 AM
Contacts	Authorizing Official	Update		CLAYTON, EDWARD J. Chief Executive Officer 5734587919	Cook, Jana Chief Financial Officer 5734587916	7/11/2017 10:39 AM
Contacts	Authorizing Official	Insert			CLAYTON, EDWARD J. Chief Executive Officer 5734587919	1/16/2017 4:44 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 11:36 AM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/10/2015 5:45 PM
Details	Last Recertification Date	Update		8/22/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 5:45 PM
Medicaid Billing	NPI: Number	Insert			1891766051	8/22/2014 8:11 AM
Details	Last Recertification Date	Update		9/5/2013 12:00:00 AM	8/22/2014 12:00:00 AM	8/22/2014 8:11 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/5/2013 12:00:00 AM	9/5/2013 1:19 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/16/2012 7:53 AM
Details	Last Recertification Date	Insert				9/23/2009 7:57 AM
Details	Grant Number	Insert				9/23/2009 7:57 AM
Details	340B ID	Insert			DSH260017	9/23/2009 7:57 AM
Details	Is Authorizing Official EHB Data	Insert				9/23/2009 7:57 AM
Dates	Last Date That 340B Drugs Purchased	Insert				9/23/2009 7:57 AM
Details	Medicare Provider Number	Insert			260017	9/23/2009 7:57 AM
Details	Entity Name	Insert			PHELPS COUNTY REGIONAL MEDICAL CENTER	9/23/2009 7:57 AM
Details	Program Code	Insert			DSH	9/23/2009 7:57 AM
Details	Entity Subname	Insert				9/23/2009 7:57 AM
Dates	Participating Approval Date	Insert			9/23/2009 12:00:00 AM	9/23/2009 7:57 AM
Details	State	Insert			Active	9/23/2009 7:57 AM
Dates	Registration Date	Insert			8/29/2005 12:00:00 AM	9/23/2009 7:57 AM
Dates	Signed By Date	Insert			7/9/2009 12:00:00 AM	9/23/2009 7:57 AM
Dates	Start Date	Insert			10/1/2009 12:00:00 AM	9/23/2009 7:57 AM
Terminations	Termination Comments	Insert				9/23/2009 7:57 AM
Terminations	Termination Date	Insert				9/23/2009 7:57 AM
Terminations	Termination Effective Date	Insert				9/23/2009 7:57 AM
Terminations	Termination Reason	Insert				9/23/2009 7:57 AM
Details	Comments Public	Insert			10/1/09 REINSTATED ORIG PART FROM 9/9/05 TO 6/30/07, NOT ELIG FROM 7/1/07 TO 9/30/09	9/23/2009 7:57 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	8/29/2005 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			010419109	8/29/2005 11:55 AM
Medicaid Billing	Medicaid: State	Insert			MO	8/29/2005 11:55 AM