| Medicaid Billing | NPI: Number | Insert | Change Request | | 1831115641 | 4/21/2025 9:11 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | AR | 4/21/2025 9:11 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1831115641 | 4/21/2025 9:11 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MO | 4/21/2025 9:11 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 010492106 (MO) | | 3/20/2025 8:20 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1831115641 (MO) | | 3/20/2025 8:20 AM |
| 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 | 8/24/2023 4:21:25 PM | 8/15/2024 2:13:24 PM | 8/15/2024 2:13 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 |
| 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 | Update | Change Request | Ozarks Medical Center DBA Ozarks Healthcare
1100 Kentucky Ave.
P.O. Box 1100
West Plains, MO 65775 | Ozarks Medical Center DBA Ozarks Healthcare
1100 Kentucky Ave.
West Plains, MO 65775 | 2/14/2024 11:49 AM |
| Medicaid Billing | NPI: Number | Insert | Group Change Request | | 1831115641 | 2/8/2024 10:02 AM |
| Medicaid Billing | NPI: State | Insert | Group Change Request | | MO | 2/8/2024 10:02 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 9/14/2023 11:32 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 010492106 | 9/14/2023 11:32 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | MO | 9/14/2023 11:32 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 8/24/2023 4:21 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 120405729 | 8/24/2023 4:21 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | AR | 8/24/2023 4:21 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 8/24/2023 4:21 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 591203005 | 8/24/2023 4:21 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MO | 8/24/2023 4:21 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1760519029 | 8/24/2023 4:21 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | AR | 8/24/2023 4:21 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1760519029 | 8/24/2023 4:21 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MO | 8/24/2023 4:21 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2022 11:25:37 AM | 8/24/2023 4:21:25 PM | 8/24/2023 4:21 PM |
| Addresses | Shipping Address | Insert | Group Change Request | | Ozarks Medical Center DBA Ozarks Healthcare
1100 Kentucky Ave.
P.O. Box 1100
West Plains, MO 65775 | 11/17/2022 8:00 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 | 10/31/2022 9:21 AM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2021 10:52:24 AM | 8/31/2022 11:25:37 AM | 8/31/2022 11:25 AM |
| 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 |
| Details | Entity Subname | Update | Change Request | GAINESVILLE MEDICAL CLINIC | Ozarks Healthcare Gainesville | 11/15/2021 11:54 AM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2020 10:57:08 AM | 9/3/2021 10:52:24 AM | 9/3/2021 10:52 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 591203005 (MO) | | 6/16/2021 8:05 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1760519029 (MO) | | 6/16/2021 8:05 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 | 6/16/2021 8:05 AM |
| Details | Entity Name | Update | Change Request | OZARKS MEDICAL CENTER | Ozarks Medical Center DBA Ozarks Healthcare | 4/16/2021 10:41 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | MO | 8/31/2020 10:57 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2019 7:41:13 AM | 8/31/2020 10:57:08 AM | 8/31/2020 10:57 AM |
| Addresses | Main Address | Update | Change Request |
404 W. HWY 160
GAINESVILLE, MO 65655 |
37 Medical Drive
GAINESVILLE, MO 65655 | 4/8/2020 10:50 AM |
| 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 |
| Contacts | Primary Contact | Update | Recertification | Poulette, Tiffany
Director of Pharmacy
Ozarks Medical Center
4172576782-5837 | MAHAN, KATIE K
DIRECTOR OF PHARMACY
OZARKS MEDICAL CENTER
4172569111-5837 | 8/29/2019 7:41 AM |
| Details | Last Recertification Date | Update | Recertification | 9/5/2018 11:07:16 AM | 8/29/2019 7:41:13 AM | 8/29/2019 7:41 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 |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/5/2018 11:07 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 591203005 | 9/5/2018 11:07 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | MO | 9/5/2018 11:07 AM |
| Details | Last Recertification Date | Update | Recertification | 11/27/2017 3:33:30 PM | 9/5/2018 11:07:16 AM | 9/5/2018 11:07 AM |
| 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 11:54 AM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2016 12:00:00 AM | 11/27/2017 3:33:30 PM | 11/27/2017 3:33 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 | Insert | | | Lane, Sherrie
340B Coordinator
4172575837 | 9/5/2016 9:12 AM |
| Addresses | Main Address | Insert | | |
404 W. HWY 160
GAINESVILLE, MO 65655 | 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 |
| 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 |
| 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 |
| Details | Last Recertification Date | Update | | 8/29/2013 2:13:11 PM | 9/3/2014 12:00:00 AM | 9/3/2014 1:04 PM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 8/29/2013 2:13:11 PM | 8/29/2013 2:13 PM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 5/7/2012 8:51 AM |
| Details | Last Recertification Date | Insert | | | | 6/18/2010 3:41 PM |
| Details | Grant Number | Insert | | | | 6/18/2010 3:41 PM |
| Details | 340B ID | Insert | | | DSH260078M | 6/18/2010 3:41 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 6/18/2010 3:41 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 6/18/2010 3:41 PM |
| Details | Medicare Provider Number | Insert | | | 260078 | 6/18/2010 3:41 PM |
| Details | Entity Name | Insert | | | OZARKS MEDICAL CENTER | 6/18/2010 3:41 PM |
| Details | Program Code | Insert | | | DSH | 6/18/2010 3:41 PM |
| Details | Entity Subname | Insert | | | GAINESVILLE MEDICAL CLINIC | 6/18/2010 3:41 PM |
| Dates | Participating Approval Date | Insert | | | 6/18/2010 12:00:00 AM | 6/18/2010 3:41 PM |
| Details | State | Insert | | | Active | 6/18/2010 3:41 PM |
| Dates | Registration Date | Insert | | | 6/3/2010 12:00:00 AM | 6/18/2010 3:41 PM |
| Dates | Signed By Date | Insert | | | 5/31/2010 12:00:00 AM | 6/18/2010 3:41 PM |
| Dates | Start Date | Insert | | | 7/1/2010 12:00:00 AM | 6/18/2010 3:41 PM |
| Terminations | Termination Comments | Insert | | | | 6/18/2010 3:41 PM |
| Terminations | Termination Date | Insert | | | | 6/18/2010 3:41 PM |
| Terminations | Termination Effective Date | Insert | | | | 6/18/2010 3:41 PM |
| Terminations | Termination Reason | Insert | | | | 6/18/2010 3:41 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1760519029 | 6/3/2010 12:07 PM |