Covered Entity Details

DSH260078 Ozarks Medical Center DBA Ozarks Healthcare (Active) - information as of 5/13/2025 1:25:09 AM

Main Details

Name

Ozarks Medical Center DBA Ozarks Healthcare

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260078

Medicare Provider Number

260078

Additional Details

Current Program Status

Active

Registration Date

9/8/2007

Participating Start Date

1/1/2005

Participating Approval Date

9/10/2007

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Ozarks Medical Center DBA Ozarks Healthcare
Lacey Carter, Chief Operating Officer
(417) 256-9111 Ext: 5968

Primary Contact

Ozarks Medical Center DBA Ozarks Healthcare
Katie Mahan, Director of 340B and Specialty Pharmacy Services
(417) 505-7700

Addresses

Street Address

1100 KENTUCKY AVENUE
WEST PLAINS, MO 65775-1100

Billing Address

Ozarks Medical Center DBA Ozarks Healthcare
PO Box 1100
West Plains, MO 65775

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
10/29/2010- UPDATED MEDICAID INFO. NOW BILLING MEDICAID; 9/5/2010- UPDATED (REMOVED) MEDICAID NUMBER (WAS 010492106);	10/29/2010

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	540492105,593965304,591203005,599301009,597387406,590052136,597843309,598302008,590492104,500087342,010492106	1831115641,1588791842,1760519029,1376679423,1295815017,1154838209,1730215195,1649306119,1558497917,1598373359
AR	130484002,186488729,120405729,129830729,126733729,264625729,333350729,311857748	1831115641,1588791842,1760519029,1154838209,1730215195,1649306119,1376679423

Shipping Addresses

Shipping Address 1

Ozarks Medical Center DBA Ozarks Healthcare Pharmacy (Retail)
1100 Kentucky Ave.
West Plains, MO 65775

Shipping Address 2

Ozarks Medical Center DBA Ozarks Healthcare Pharmacy
307 N. Kentucky Avenue
West Plains, MO 65775

Shipping Address 3

Ozarks Medical Center dba Ozarks Healthcare Pharmacy Thayer
1375 Nettleton Ave
Thayer, MO 65791

Shipping Address 4

Ozarks Medical Center DBA Ozarks Healthcare Pharmacy Gainesville
512 Third Street
Gainesville, MO 65655

Shipping Address 5

Ozarks Medical Center DBA Ozarks Healthcare Specialty Pharmacy
18 Parkway Shopping Ctr.
West Plains, MO 65775

Shipping Address 6

Ozarks Medical Center DBA Ozarks Healthcare Pharmacy Mountain Grove
500 E. 19th Street
Suite D
Mountain Grove, MO 65711

Shipping Address 7

Ozarks Medical Center DBA Ozarks Healthcare Infusion Pharmacy
1100 Kentucky Ave.
West Plains, MO 65775

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/08/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/08/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/08/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/08/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/08/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/08/2022	07/01/2022	08/15/2023	09/13/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/12/2022	07/01/2022		07/01/2022
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/06/2020	07/01/2020		07/01/2020
Contract Detail	AETNA SPECIALTY PHARMACY, LLC	503 SUNPORT LN		ORLANDO	FL	32809-7874	07/15/2020	10/01/2020	09/30/2021	02/08/2024
Contract Detail	ALPS LONG TERM CARE PHARMACY	105 S RIDGECREST AVE STE 2		NIXA	MO	65714	04/16/2021	07/01/2021	04/01/2024	04/01/2024
Contract Detail	ALPS SPECIALTY PHARMACY	105 S RIDGECREST AVE STE 3A		NIXA	MO	65714	07/11/2019	10/01/2019	04/01/2024	04/01/2024
Contract Detail	ALTON DRUG STORE	C AND P ALTON VENTURES LLC	201 STATE HIGHWAY 19	ALTON	MO	65606	10/10/2019	01/01/2020		01/01/2020
Contract Detail	BAKER'S PHARMACY	BAKER AND BAKER INC	106 WEST HIGHWAY 62 PO BOX 247	SALEM	AR	72576	07/11/2014	10/01/2014	10/06/2015	09/02/2016
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	07/02/2024	10/01/2024		10/01/2024
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	04/06/2018	07/01/2018	10/01/2019	11/25/2019
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	04/06/2018	07/01/2018	10/01/2019	11/25/2019
Contract Detail	BURTON CREEK PHARMACY	GANT PHARMACY SERVICES INC	805 KENTUCKY, SUITE 2	WEST PLAINS	MO	65775	03/28/2011	03/28/2011	06/03/2019	10/31/2019
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/17/2017	07/01/2017	09/13/2022	10/11/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/17/2017	07/01/2017		04/17/2017
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/17/2017	07/01/2017		04/17/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/17/2017	07/01/2017	09/13/2022	10/11/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/17/2017	07/01/2017	09/13/2022	10/11/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/17/2017	07/01/2017	09/13/2022	10/11/2022
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/17/2017	07/01/2017	09/13/2022	10/11/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/17/2017	07/01/2017		04/17/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/17/2017	07/01/2017	09/13/2022	10/11/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/12/2022	07/01/2022	09/13/2022	10/11/2022
Contract Detail	COURT SQUARE PHARMACY	512 W 3RD ST	PO BOX 414	GAINESVILLE	MO	65655	09/22/2011	09/22/2011	09/30/2022	10/03/2022
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/08/2022	07/01/2022		07/01/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/12/2022	07/01/2022		07/01/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/18/2020	10/01/2020		10/01/2020
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/15/2020	10/01/2020		10/01/2020
Contract Detail	DAVIDSON DRUG	200 WARMFORK RD		THAYER	MO	65791-7510	04/06/2020	07/01/2020	10/12/2021	10/14/2021
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/11/2019	10/01/2019	04/14/2022	09/26/2022
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	04/15/2024	07/01/2024		07/01/2024
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/08/2022	07/01/2022		07/01/2022
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/08/2022	07/01/2022		07/01/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/08/2022	07/01/2022		07/01/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/08/2022	07/01/2022		07/01/2022
Contract Detail	FAMILY PHARMACY, LLC	1600 N MAIN		MOUNTAIN GROVE	MO	65711	10/18/2016	01/01/2017	11/17/2022	02/08/2024
Contract Detail	LEXI'S MEDICINE, INC	8499 ASH AVE		WINONA	MO	65588	04/15/2016	07/01/2016		09/02/2016
Contract Detail	LIBERTY PHARMACY	RKJ HOLDINGS LLC	508-2 W. US 60	MOUNTAIN VIEW	MO	65548	01/13/2016	04/01/2016	10/14/2016	03/30/2024
Contract Detail	MIKE STUART ENTERPRISES, INC.	LAKELAND PHARMACY #7	110 BEAR DR STE 4	WILLOW SPRINGS	MO	65793-7102	01/12/2017	04/01/2017	11/16/2022	01/04/2023
Contract Detail	MISSOURI CVS PHARMACY, L.L.C.	CVS/PHARMACY #11407	805 N KENTUCKY AVE, STE 2	WEST PLAINS	MO	65775	08/28/2019	10/01/2019		10/01/2019
Contract Detail	MOUNTAIN GROVE PHARMACY	106 N UNION		MOUNTAIN GROVE	MO	65711	04/02/2018	07/01/2018	11/17/2022	02/08/2024
Contract Detail	MYERS PHARMACY	S & W HEALTHCARE LLC	603 N HWY 160	ALTON	MO	65606	07/14/2013	10/01/2013	01/18/2018	01/18/2018
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	10/31/2012	10/31/2012		09/02/2016
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/06/2018	07/01/2018	09/23/2020	10/08/2020
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	07/23/2021	09/08/2021		09/08/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/08/2022	04/13/2022	05/05/2023	06/02/2023
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/11/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/06/2018	07/01/2018	05/05/2023	06/02/2023
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/06/2018	07/01/2018		04/06/2018
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	07/23/2021	09/08/2021		09/08/2021
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	04/06/2018	07/01/2018	05/05/2023	06/02/2023
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/23/2021	09/08/2021	05/05/2023	06/02/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/23/2021	09/08/2021		09/08/2021
Contract Detail	OZARKS MEDICAL CTR DBA OZARKS HEALTHCARE	1100 N KENTUCKY AVE		WEST PLAINS	MO	65775	02/27/2013	04/01/2013	09/23/2020	09/29/2020
Contract Detail	PALACE DRUG	270 MAIN ST		MAMMOTH SPRING	AR	72554-7466	07/27/2011	07/27/2011		09/02/2016
Contract Detail	PALACE DRUG OF SALEM	PALACE DRUG OF SALEM LLC	106 HIGHWAY 62 W	SALEM	AR	72576	10/06/2015	01/01/2016		09/02/2016
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/15/2020	10/01/2020	10/01/2022	10/11/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/17/2017	07/01/2017	09/13/2022	10/11/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/21/2025	07/01/2025		04/21/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/08/2022	07/01/2022	09/13/2022	10/11/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/12/2022	07/01/2022	09/13/2022	10/11/2022
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	04/12/2022	07/01/2022	09/13/2022	10/11/2022
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/15/2024	07/01/2024		07/01/2024
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	02/14/2012	02/14/2012		09/02/2016
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/04/2017	07/01/2017		04/04/2017
Contract Detail	SUPER D DRUGS ACQUISITION CO.	DBA: FORBES PHARMACY #15722	POWERED BY WALGREENS 100 NORTH GRAND	HOUSTON	MO	65483	07/11/2013	10/01/2013	02/29/2024	03/18/2024
Contract Detail	SUPER D DRUGS ACQUISITION CO.	AVA DRUG #15726, POWERED BY WALGREENS	124 W WASHINGTON AVE	AVA	MO	65608	07/11/2013	10/01/2013		09/02/2016
Contract Detail	SUPER D DRUGS ACQUISITION CO.	MANSFIELD DRUG #15731	POWERED BY WALGREENS 101 N BUSINESS HWY 60	MANSFIELD	MO	65704	07/11/2013	10/01/2013		09/02/2016
Contract Detail	SUPER D DRUGS ACQUISITION CO.	D/B/A FERGUSON DRUGS # 15803	POWERED BY WALGREENS 101 EAST MAIN STREET	WILLOW SPRINGS	MO	65793-1413	07/11/2013	10/01/2013	06/09/2023	07/10/2023
Contract Detail	THEODOSIA PHARMACY	4900 US HIGHWAY 160	STE 1	THEODOSIA	MO	65761	09/22/2011	09/22/2011	01/01/2020	02/25/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/17/2017	04/01/2017		01/17/2017
Contract Detail	WAL-MART PHARMACY 10-0015	1310 PREACHER ROE BLVD		WEST PLAINS	MO	65775	02/28/2013	04/01/2013		09/02/2016
Contract Detail	WAL-MART PHARMACY 10-0088	2100 N MAIN		MOUNTAIN GROVE	MO	65711	04/03/2015	07/01/2015		09/02/2016
Contract Detail	WAL-MART PHARMACY 10-0166	1433 SOUTH SAM HOUSTON BLVD.		HOUSTON	MO	65483	07/13/2015	10/01/2015		09/02/2016
Contract Detail	WAL-MART PHARMACY 10-0837	333 E WALNUT		THAYER	MO	65791	02/26/2013	04/01/2013		09/02/2016
Contract Detail	WAL-MART PHARMACY 10-0871	101 WEST HIGHWAY 60		MT VIEW	MO	65548	02/26/2013	04/01/2013		09/02/2016
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/17/2017	04/01/2017		01/17/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #11288	1010 WORLEY DRIVE	WEST PLAINS	MO	65775	12/02/2010	12/02/2010		09/02/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15054	124 W 2ND ST	MOUNTAIN VIEW	MO	65548	12/08/2010	12/10/2010	01/27/2025	02/04/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09743	350 HWY 62 EAST	MOUTAIN HOME	AR	72653-3629	07/11/2013	10/01/2013		09/02/2016
Contract Detail	Walgreens Central Fill #21394	2601 Hughes Road	Suite 103	Liberty	MO	64068	07/10/2023	10/01/2023		10/01/2023
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/11/2013	10/01/2013	07/08/2015	09/02/2016
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/15/2020	10/01/2020		10/01/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/15/2020	10/01/2020	01/19/2022	03/02/2022
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/11/2023	01/01/2024		01/01/2024
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/11/2023	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH260078AA	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Imaging-Radiation Therapy	1111 Kentucky Avenue	West Plains	MO	Terminated
DSH260078AB	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Pediatrics	312 Kentucky Avenue	West Plains	MO	Active
DSH260078AC	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Mammoth Spring	260 Main Street	Mammoth Spring	AR	Terminated
DSH260078AD	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Zizzer Clinic	1013 College Street	West Plains	MO	Active
DSH260078AE	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Medical Center DBA Ozarks Healthcare Dermatology - Dermatology	1210 N. Kentucky Ave	West Plains	MO	Active
DSH260078B	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare West Plains - Family Medicine	181 KENTUCKY AVE., SUITE 100	WEST PLAINS	MO	Active
DSH260078C	Child	DSH	OZARKS MEDICAL CENTER	SALEM FIRST CARE	172 HWY 62 EAST, SUITE 1	SALEM	AR	Terminated
DSH260078D	Child	DSH	OZARKS MEDICAL CENTER	MAMMOTH SPRINGS MEDICAL CLINIC	236 S. MAIN ST	MAMMOTH SPRINGS	AR	Terminated
DSH260078E	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Thayer	1375 Nettleton Avenue	THAYER	MO	Active
DSH260078F	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Alton	100 MEDICAL DRIVE	ALTON	MO	Active
DSH260078G	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Winona	9104 State Hwy 19	WINONA	MO	Active
DSH260078H	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Mountain View	220 N. ELM STREET	MT. VIEW	MO	Active
DSH260078J	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Mountain Grove	500 East 19th Street	MT. GROVE	MO	Active
DSH260078L	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Behavioral Health Center	1211 Porter Wagoner Blvd	WEST PLAINS	MO	Terminated
DSH260078M	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Gainesville	37 Medical Drive	GAINESVILLE	MO	Active
DSH260078N	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Cancer Treatment Center	1111 Kentucky Avenue	West Plains	MO	Terminated
DSH260078P	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Rheumatology	2900 Independence Square	West Plains	MO	Terminated
DSH260078Q	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Pain Center	3000 Independence Square	West Plains	MO	Terminated
DSH260078R	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Neuroscience Center	1100 Kentucky Avenue	West Plains	MO	Terminated
DSH260078S	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Wound Care	1665 Gibson Street	West Plains	MO	Active
DSH260078T	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Heart Care Services	1115 Alaska Street	West Plains	MO	Terminated
DSH260078U	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	Ozarks Healthcare Imaging	3102 Independence Square	West Plains	MO	Terminated
DSH260078V	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	WPI Ultrasound	3102 Independence Square	West Plains	MO	Terminated
DSH260078W	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	WPI OP Radiation Therapy	3102 Independence Square	West Plains	MO	Terminated
DSH260078X	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	WPI Nuclear Medicine	3102 Independence Square	West Plains	MO	Terminated
DSH260078Y	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	WPI CT Scan	3102 Independence Square	West Plains	MO	Terminated
DSH260078Z	Child	DSH	Ozarks Medical Center DBA Ozarks Healthcare	WPI MRI	3102 Independence Square	West Plains	MO	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Change Request	226191002 (AR)		3/20/2025 8:22 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500101511 (MO)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	505646406 (MO)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	592966105 (MO)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	107972105 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	505451002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	266332002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	205454002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	189020002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	118737729 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	189014002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	187743002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	205450002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	188310002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	278611407 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	195101002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	205452004 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	189015002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		126733729	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		264625729	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		333350729	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		311857748	3/10/2025 12:34 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	3/10/2025 12:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1396343935 (MO)		3/10/2025 12:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1750680146 (MO)		3/10/2025 12:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649306002 (MO)		3/10/2025 12:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1750680146 (AR)		3/10/2025 12:34 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649306002 (AR)		3/10/2025 12:34 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1376679423	3/10/2025 12:34 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	3/10/2025 12:34 PM
Contacts	Authorizing Official	Update	Profile Change Request	Carter, Lacey Chief Operations Officer - Chief Nursing Officer Ozarks Medical Center DBA Ozarks Healthcare 4172569111-5968	Carter, Lacey Chief Operating Officer Ozarks Medical Center DBA Ozarks Healthcare 4172569111-5968	2/5/2025 6:56 AM
Contacts	Primary Contact	Update	Profile Change Request	Mahan, Katie 340B Director Ozarks Medical Center DBA Ozarks Healthcare 4175057700	Mahan, Katie Director of 340B and Specialty Pharmacy Services Ozarks Medical Center DBA Ozarks Healthcare 4175057700	11/5/2024 11:24 AM
Contacts	Authorizing Official	Update	Change Request	Goodin, Scott W Interim CFO Ozarks Medical Center DBA Ozarks Healthcare 4172569111	Carter, Lacey Chief Operations Officer - Chief Nursing Officer Ozarks Medical Center DBA Ozarks Healthcare 4172569111-5968	10/7/2024 7:08 AM
Contacts	Primary Contact	Update	Profile Change Request	Mahan, Katie 340B Pharmacy Program Manager Ozarks Medical Center DBA Ozarks Healthcare 4175057700	Mahan, Katie 340B Director Ozarks Medical Center DBA Ozarks Healthcare 4175057700	8/23/2024 10:52 AM
Details	Last Recertification Date	Update	Recertification	8/30/2023 7:16:42 AM	8/19/2024 4:19:32 PM	8/19/2024 4:19 PM
Contacts	Primary Contact	Update	Profile Change Request	Mahan, Katie Director of Retail Pharmacy/340B Ozarks Medical Center DBA Ozarks Healthcare 4175057700	Mahan, Katie 340B Pharmacy Program Manager Ozarks Medical Center DBA Ozarks Healthcare 4175057700	8/5/2024 1:54 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	505622704 (MO)		7/17/2024 10:03 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	198015002 (AR)		7/17/2024 10:03 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	187742002 (AR)		7/17/2024 10:03 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/17/2024 10:03 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		189015002	7/17/2024 10:03 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	7/17/2024 10:03 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1750670956 (MO)		7/17/2024 10:03 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1750670956 (AR)		7/17/2024 10:03 AM
Contacts	Authorizing Official	Update	Change Request	Cook, Nichole Vice President of Finance Ozarks Medical Center dba Ozarks Healthcare 4172569111-6010	Goodin, Scott W Interim CFO Ozarks Medical Center DBA Ozarks Healthcare 4172569111	6/5/2024 1:31 PM
Contacts	Primary Contact	Update	Profile Change Request	Mahan, Katie Pharmacy Director Ozarks Medical Center DBA Ozarks Healthcare 4172561793	Mahan, Katie Director of Retail Pharmacy/340B Ozarks Medical Center DBA Ozarks Healthcare 4175057700	2/20/2024 1:54 PM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center DBA Ozarks Healthcare Infusion Pharmacy 1100 Kentucky Ave. West Plains, MO 65775	2/20/2024 8:16 AM
Addresses	Shipping Address	Update	Change Request	Ozarks Medical Center DBA Ozarks Healthcare Pharmacy (Retail) 1100 N. Kentucky Ave. West Plains, MO 65775	Ozarks Medical Center DBA Ozarks Healthcare Pharmacy (Retail) 1100 Kentucky Ave. West Plains, MO 65775	2/8/2024 1:29 PM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center DBA Ozarks Healthcare Pharmacy Mountain Grove 500 E. 19th Street Suite D Mountain Grove, MO 65711	11/14/2023 8:37 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/13/2023 3:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010492106	9/13/2023 3:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	9/13/2023 3:55 PM
Details	Last Recertification Date	Update	Recertification	9/7/2022 8:05:47 AM	8/30/2023 7:16:42 AM	8/30/2023 7:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		540492105	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		593965304	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500101511	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		591203005	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		505646406	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		592966105	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		599301009	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		597387406	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		590052136	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		597843309	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		598302008	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		590492104	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		505622704	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		500087342	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		130484002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		186488729	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		107972105	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		505451002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		266332002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		120405729	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		198015002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		205454002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		189020002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		118737729	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		189014002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		187743002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		226191002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		205450002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		188310002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		278611407	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		195101002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		129830729	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		187742002	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		205452004	6/7/2023 5:12 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1831115641	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1588791842	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1396343935	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1760519029	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1750680146	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649306002	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1376679423	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1295815017	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154838209	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730215195	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649306119	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558497917	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1750670956	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598373359	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		MO	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1831115641	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1588791842	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1760519029	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1750680146	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649306002	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154838209	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730215195	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649306119	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1750670956	6/7/2023 5:12 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	6/7/2023 5:12 PM
Addresses	Shipping Address	Update	Change Request	Ozarks Medical Center DBA Ozarks Healthcare Pharmacy Gainesville 512 W Third Street Gainesville, MO 65655	Ozarks Medical Center DBA Ozarks Healthcare Pharmacy Gainesville 512 Third Street Gainesville, MO 65655	10/27/2022 6:42 AM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center DBA Ozarks Healthcare Pharmacy Gainesville 512 W Third Street Gainesville, MO 65655	10/4/2022 9:32 AM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center DBA Ozarks Healthcare Specialty Pharmacy 18 Parkway Shopping Ctr. West Plains, MO 65775	10/4/2022 9:32 AM
Details	Last Recertification Date	Update	Recertification	9/3/2021 10:48:07 AM	9/7/2022 8:05:47 AM	9/7/2022 8:05 AM
Addresses	Shipping Address	Update	Change Request	Ozarks Medical Center DBA Ozarks Healthcare Pharmacy 18 Parkway Center West Plains, MO 65775	Ozarks Medical Center DBA Ozarks Healthcare Pharmacy (Retail) 1100 N. Kentucky Ave. West Plains, MO 65775	8/2/2022 12:10 PM
Addresses	Shipping Address	Delete	Change Request	Ozarks Medical Center DBA Ozarks Healthcare Pharmacy Thayer 200 Warmfork Road Thayer, MO 65791-7510		3/21/2022 3:04 PM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center dba Ozarks Healthcare Pharmacy Thayer 1375 Nettleton Ave Thayer, MO 65791	3/21/2022 3:04 PM
Contacts	Authorizing Official	Update	Change Request	Cook, Nichole Vice President of Finance Ozarks Medical Center 4172569111-6010	Cook, Nichole Vice President of Finance Ozarks Medical Center dba Ozarks Healthcare 4172569111-6010	3/2/2022 2:55 PM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center DBA Ozarks Healthcare Pharmacy 307 N. Kentucky Avenue West Plains, MO 65775	12/15/2021 8:07 AM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center DBA Ozarks Healthcare Pharmacy Thayer 200 Warmfork Road Thayer, MO 65791-7510	10/14/2021 1:32 PM
Details	Last Recertification Date	Update	Recertification	8/27/2020 12:14:40 PM	9/3/2021 10:48:07 AM	9/3/2021 10:48 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	010492106 (MO)		6/15/2021 6:27 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1831115641 (MO)		6/15/2021 6:27 PM
Addresses	Shipping Address	Delete	Change Request	Ozarks Medical Center Employee Pharmacy 18 Parkway Center West Plains, MO 65775		4/16/2021 10:41 AM
Addresses	Billing Address	Update	Change Request	Ozarks Medical Center PO Box 1100 West Plains, MO 65775	Ozarks Medical Center DBA Ozarks Healthcare PO Box 1100 West Plains, MO 65775	4/16/2021 10:41 AM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center DBA Ozarks Healthcare Pharmacy 18 Parkway Center West Plains, MO 65775	4/16/2021 10:41 AM
Contacts	Primary Contact	Update	Change Request	MAHAN, KATIE K DIRECTOR OF PHARMACY OZARKS MEDICAL CENTER 4172569111-5837	Mahan, Katie Pharmacy Director Ozarks Medical Center DBA Ozarks Healthcare 4172561793	4/16/2021 10:41 AM
Details	Entity Name	Update	Change Request	OZARKS MEDICAL CENTER	Ozarks Medical Center DBA Ozarks Healthcare	4/16/2021 10:41 AM
Addresses	Main Address	Update	Change Request	1100 KENTUCKY AVENUE WEST PLAINS, MO 65775	1100 KENTUCKY AVENUE WEST PLAINS, MO 65775-1100	9/7/2020 12:53 PM
Addresses	Shipping Address	Insert	Change Request		Ozarks Medical Center Employee Pharmacy 18 Parkway Center West Plains, MO 65775	9/7/2020 12:53 PM
Medicaid Billing	NPI: State	Update	Recertification		MO	8/27/2020 12:14 PM
Details	Last Recertification Date	Update	Recertification	8/29/2019 7:34:09 AM	8/27/2020 12:14:40 PM	8/27/2020 12:14 PM
Contacts	Authorizing Official	Update	Change Request	Pollard, Timothy J CFO Ozarks Medical Center 4172569111-6031	Cook, Nichole Vice President of Finance Ozarks Medical Center 4172569111-6010	1/3/2020 10:33 AM
Details	Last Recertification Date	Update	Recertification	9/5/2018 12:11:15 PM	8/29/2019 7:34:09 AM	8/29/2019 7:34 AM
Contacts	Primary Contact	Update	Change Request	Poulette, Tiffany Director of Pharmacy Ozarks Medical Center 4172576782-5837	MAHAN, KATIE K DIRECTOR OF PHARMACY OZARKS MEDICAL CENTER 4172569111-5837	8/2/2019 10:06 AM
Contacts	Authorizing Official	Update	AO Change Request	Thompson, Kim CFO Ozarks Medical Center 4172569111-6031	Pollard, Timothy J CFO Ozarks Medical Center 4172569111-6031	7/1/2019 12:03 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 7:38:34 PM	9/5/2018 12:11:15 PM	9/5/2018 12:11 PM
Contacts	Primary Contact	Update	Change Request	Lane, Sherrie 340B Coordinator Ozarks Medical Center 4172575837	Poulette, Tiffany Director of Pharmacy Ozarks Medical Center 4172576782-5837	4/2/2018 11:05 AM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	11/29/2017 7:38:34 PM	11/29/2017 7:38 PM
Contacts	Primary Contact	Update	Recertification	Lane, Sherrie 340B Coordinator 4172575837	Lane, Sherrie 340B Coordinator Ozarks Medical Center 4172575837	11/27/2017 10:18 AM
Contacts	Authorizing Official	Update		Thompson, Kim CFO 4172569111-6031	Thompson, Kim CFO Ozarks Medical Center 4172569111-6031	9/19/2017 11:57 AM
Contacts	Authorizing Official	Insert			Thompson, Kim CFO 4172569111-6031	4/17/2017 10:15 AM
Contacts	Primary Contact	Update		OGDEN, NATHAN 340B PROGRAM MANAGER 4178535290	Lane, Sherrie 340B Coordinator 4172575837	9/5/2016 9:12 AM
Addresses	Main Address	Insert			1100 KENTUCKY AVENUE WEST PLAINS, MO 65775	9/2/2016 4:22 PM
Addresses	Billing Address	Insert			Ozarks Medical Center PO Box 1100 West Plains, MO 65775	9/2/2016 4:22 PM
Medicaid Billing	NPI: Number	Update		1831115642	1831115641	9/2/2016 4:22 PM
Details	Last Recertification Date	Update		8/13/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 12:44 PM
Medicaid Billing	NPI: Number	Insert			1831115642	6/28/2016 5:48 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/13/2015 2:23 PM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	8/13/2015 12:00:00 AM	8/13/2015 2:23 PM
Contacts	Primary Contact	Insert			OGDEN, NATHAN 340B PROGRAM MANAGER 4178535290	9/3/2014 1:03 PM
Details	Last Recertification Date	Update		8/29/2013 12:00:00 AM	9/3/2014 12:00:00 AM	9/3/2014 1:03 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/29/2013 12:00:00 AM	8/29/2013 2:13 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/7/2012 8:50 AM
Details	Last Recertification Date	Insert				10/29/2010 3:17 PM
Details	Grant Number	Insert				10/29/2010 3:17 PM
Details	340B ID	Insert			DSH260078	10/29/2010 3:17 PM
Details	Is Authorizing Official EHB Data	Insert				10/29/2010 3:17 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/29/2010 3:17 PM
Details	Medicare Provider Number	Insert			260078	10/29/2010 3:17 PM
Details	Entity Name	Insert			OZARKS MEDICAL CENTER	10/29/2010 3:17 PM
Details	Program Code	Insert			DSH	10/29/2010 3:17 PM
Details	Entity Subname	Insert				10/29/2010 3:17 PM
Dates	Participating Approval Date	Insert			9/10/2007 12:00:00 AM	10/29/2010 3:17 PM
Details	State	Insert			Active	10/29/2010 3:17 PM
Dates	Registration Date	Insert			9/8/2007 12:00:00 AM	10/29/2010 3:17 PM
Dates	Signed By Date	Insert				10/29/2010 3:17 PM
Dates	Start Date	Insert			1/1/2005 12:00:00 AM	10/29/2010 3:17 PM
Terminations	Termination Comments	Insert				10/29/2010 3:17 PM
Terminations	Termination Date	Insert				10/29/2010 3:17 PM
Terminations	Termination Effective Date	Insert				10/29/2010 3:17 PM
Terminations	Termination Reason	Insert				10/29/2010 3:17 PM
Details	Comments Public	Insert			10/29/2010- UPDATED MEDICAID INFO. NOW BILLING MEDICAID; 9/5/2010- UPDATED (REMOVED) MEDICAID NUMBER (WAS 010492106);	10/29/2010 3:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	9/8/2007 1:59 PM
Medicaid Billing	Medicaid: Number	Insert			010492106	9/8/2007 1:59 PM
Medicaid Billing	Medicaid: State	Insert			MO	9/8/2007 1:59 PM