| Details | Last Recertification Date | Update | Recertification | 8/22/2023 2:14:42 PM | 9/5/2024 11:53:03 AM | 9/5/2024 11:53 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Thompson, Tony
Hospital Administrator
Izard Regional Hospital
8702973726 | Smith, Richard Harley
Interim Administrator
Izard Regional Hospital
2192309682 | 8/28/2024 10:10 AM |
| Details | Last Recertification Date | Update | Recertification | | 8/22/2023 2:14:42 PM | 8/22/2023 2:14 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Skidmore, Kim
Hospital Administrator
Izard Regional Hospital
8702978400 | Thompson, Tony
Hospital Administrator
Izard Regional Hospital
8702973726 | 8/21/2023 2:09 PM |
| Details | State | Update | | Approved | Active | 4/1/2023 12:01 AM |
| Addresses | Billing Address | Update | Change Request | Izard Regional Hospital, LLC
10996 Four Seasons Place
Crown Point, IN 46307-7762 | Izard Regional Hospital, LLC
10996 Four Seasons Place
100C
Crown Point, IN 46307-7762 | 3/15/2023 3:57 PM |
| Addresses | Shipping Address | Delete | Change Request | Izard Regional Hospital
61 Grasse Street
Calico Rock, AR 72519 | | 3/15/2023 3:57 PM |
| Addresses | Main Address | Update | Change Request |
PARK ST
CALICO ROCK, AR 72519 |
61 GRASSE ST
CALICO ROCK, AR 72519 | 3/15/2023 3:57 PM |
| Details | Entity Name | Update | Change Request | COMM MEDICAL CENTER OF CALICO ROCK | IZARD REGIONAL HOSPITAL, LLC | 3/15/2023 3:57 PM |
| Addresses | Billing Address | Insert | Reinstatement | | Izard Regional Hospital, LLC
10996 Four Seasons Place
Crown Point, IN 46307-7762 | 3/13/2023 2:09 PM |
| Addresses | Shipping Address | Insert | Reinstatement | | Izard Regional Hospital
61 Grasse Street
Calico Rock, AR 72519 | 3/13/2023 2:09 PM |
| Addresses | Main Address | Update | Reinstatement |
61 Grasse St
Calico Rock, AR 72519-0438 |
PARK ST
CALICO ROCK, AR 72519 | 3/13/2023 2:09 PM |
| Contacts | Primary Contact | Update | Reinstatement | McClain, Jessica
Director of Pharmacy
8702972462 | Tang, Lisa
340B Program Director
Boa Vida Healthcare
3173241466 | 3/13/2023 2:09 PM |
| Contacts | Authorizing Official | Update | Reinstatement | Farnell, Lee
Interim CEO
8702972400 | Skidmore, Kim
Hospital Administrator
Izard Regional Hospital
8702978400 | 3/13/2023 2:09 PM |
| Contacts | Signed By | Update | Reinstatement | Hughes, Philip
CEO
8702972400 | Skidmore, Kim
Hospital Administrator
Izard Regional Hospital
8702978400 | 3/13/2023 2:09 PM |
| Details | Last Recertification Date | Update | Reinstatement | 9/14/2013 12:00:00 AM | | 3/13/2023 2:09 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 10/1/2013 12:00:00 AM | | 3/13/2023 2:09 PM |
| Details | Entity Name | Update | Reinstatement | Community Medical Center of Izard County | COMM MEDICAL CENTER OF CALICO ROCK | 3/13/2023 2:09 PM |
| Dates | Participating Approval Date | Update | Reinstatement | 2/16/2012 12:00:00 AM | 3/13/2023 2:09:31 PM | 3/13/2023 2:09 PM |
| Details | State | Update | Reinstatement | Terminated | Approved | 3/13/2023 2:09 PM |
| Dates | Registration Date | Update | Reinstatement | 1/30/2012 12:00:00 AM | 1/16/2023 3:15:25 PM | 3/13/2023 2:09 PM |
| Dates | Signed By Date | Update | Reinstatement | 1/30/2012 12:00:00 AM | 3/10/2023 9:59:37 AM | 3/13/2023 2:09 PM |
| Dates | Start Date | Update | Reinstatement | 4/1/2012 12:00:00 AM | 4/1/2023 12:00:00 AM | 3/13/2023 2:09 PM |
| Terminations | Termination Date | Update | Reinstatement | 10/1/2013 12:00:00 AM | | 3/13/2023 2:09 PM |
| Terminations | Termination Effective Date | Update | Reinstatement | 10/1/2013 12:00:00 AM | | 3/13/2023 2:09 PM |
| Terminations | Termination Reason | Update | Reinstatement | Failure to recertify | | 3/13/2023 2:09 PM |
| Details | Comments Public | Insert | Reinstatement | | Participated starting 4/1/2012; Terminated 10/1/2013; Reinstated 4/1/2023. | 3/13/2023 1:35 PM |
| Contacts | Primary Contact | Insert | | | McClain, Jessica
Director of Pharmacy
8702972462 | 7/3/2014 4:20 PM |
| Contacts | Authorizing Official | Insert | | | Farnell, Lee
Interim CEO
8702972400 | 7/3/2014 4:20 PM |
| Contacts | Signed By | Insert | | | Hughes, Philip
CEO
8702972400 | 7/3/2014 4:20 PM |
| Addresses | Main Address | Insert | | |
61 Grasse St
Calico Rock, AR 72519-0438 | 9/14/2013 7:58 AM |
| Details | Last Recertification Date | Update | | | 9/14/2013 12:00:00 AM | 9/14/2013 7:58 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 10/1/2013 12:00:00 AM | 9/14/2013 7:58 AM |
| Details | State | Update | | Active | Terminated | 9/14/2013 7:58 AM |
| Terminations | Termination Date | Update | | | 10/1/2013 12:00:00 AM | 9/14/2013 7:58 AM |
| Terminations | Termination Effective Date | Update | | | 10/1/2013 12:00:00 AM | 9/14/2013 7:58 AM |
| Terminations | Termination Reason | Update | | | Failure to recertify | 9/14/2013 7:58 AM |
| Addresses | Billing Address | Insert | | | Community Medical Center of Izard County
PO BOX 438
Calico Rock, AR 72519-0438 | 6/6/2012 12:55 PM |
| Details | 340B ID | Update | | IS-CA-CAH041306-00 | CAH041306-00 | 2/16/2012 3:39 PM |
| Dates | Participating Approval Date | Update | | | 2/16/2012 12:00:00 AM | 2/16/2012 3:39 PM |
| Details | State | Update | | Pending | Active | 2/16/2012 3:39 PM |
| Dates | Start Date | Update | | | 4/1/2012 12:00:00 AM | 2/16/2012 3:39 PM |
| Details | 340B ID | Update | | CA-CAH041306-00 | IS-CA-CAH041306-00 | 2/10/2012 5:46 PM |
| Details | 340B ID | Update | | CA013012D | CA-CAH041306-00 | 2/7/2012 12:19 PM |
| Details | 340B ID | Update | | ONLINE_REG | CA013012D | 1/30/2012 8:42 PM |
| Details | Last Recertification Date | Insert | | | | 1/30/2012 1:45 PM |
| Details | Grant Number | Insert | | | | 1/30/2012 1:45 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 1/30/2012 1:45 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/30/2012 1:45 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/30/2012 1:45 PM |
| Details | Medicare Provider Number | Insert | | | 041306 | 1/30/2012 1:45 PM |
| Details | Entity Name | Insert | | | Community Medical Center of Izard County | 1/30/2012 1:45 PM |
| Details | Program Code | Insert | | | CAH | 1/30/2012 1:45 PM |
| Details | Entity Subname | Insert | | | | 1/30/2012 1:45 PM |
| Dates | Participating Approval Date | Insert | | | | 1/30/2012 1:45 PM |
| Details | State | Insert | | | Pending | 1/30/2012 1:45 PM |
| Dates | Registration Date | Insert | | | 1/30/2012 12:00:00 AM | 1/30/2012 1:45 PM |
| Dates | Signed By Date | Insert | | | 1/30/2012 12:00:00 AM | 1/30/2012 1:45 PM |
| Dates | Start Date | Insert | | | | 1/30/2012 1:45 PM |
| Terminations | Termination Comments | Insert | | | | 1/30/2012 1:45 PM |
| Terminations | Termination Date | Insert | | | | 1/30/2012 1:45 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/30/2012 1:45 PM |
| Terminations | Termination Reason | Insert | | | | 1/30/2012 1:45 PM |