Covered Entity Details

SCH460019-01 Uintah Basin Medical Center (Active) - information as of 4/28/2025 1:48:51 AM

Main Details

Name

Uintah Basin Medical Center

Subdivision Name

Uintah Basin Medical Center Roosevelt Dialysis

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH460019-01

Medicare Provider Number

460019

Outpatient Facility Provider Number

463505

Additional Details

Current Program Status

Active

Registration Date

1/9/2013

Participating Start Date

4/1/2013

Participating Approval Date

3/11/2013

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Uintah Basin Medical Center
Brent Hales, CFO
(435) 722-6164

Primary Contact

Uintah Basin Medical Center
Weston Ross Weaver, Outpatient Pharmacy Manager
(435) 722-4691 Ext: 2054

Addresses

Street Address

205 W 300 N
Roosevelt, UT 84066

Billing Address

Uintah Basin Medical Center
250 W 300 N
Roosevelt, UT 84066

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

Uintah Basin Medical Center
250 W 300 N
Roosevelt, UT 84066

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
SCH460019-01	Child	SCH	Uintah Basin Medical Center	Uintah Basin Medical Center Roosevelt Dialysis	205 W 300 N	Roosevelt	UT	Active
SCH460019-02	Child	SCH	Uintah Basin Medical Center	Uintah Basin Medical Center Vernal Dialysis	405 N 500 W	Vernal	UT	Active
SCH460019-03	Child	SCH	Uintah Basin Medical Center	UINTAH BASIN MEDICAL CENTER, INC - Duchesne Valley Medical Clinic	50 E 200 S	DUCHESNE	UT	Active
SCH460019-04	Child	SCH	Uintah Basin Medical Center	UINTAH BASIN HEALTHCARE VERNAL - Infusion Services	405 N 500 W	VERNAL	UT	Active
SCH460019-05	Child	SCH	Uintah Basin Medical Center	UINTAH BASIN MEDICAL CENTER - Emergency	405 N 500 W	VERNAL	UT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/14/2023 1:55:09 PM	8/12/2024 3:22:27 PM	8/12/2024 3:22 PM
Details	Last Recertification Date	Update	Recertification	8/24/2022 7:09:19 PM	8/14/2023 1:55:09 PM	8/14/2023 1:55 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 1:04:50 PM	8/24/2022 7:09:19 PM	8/24/2022 7:09 PM
Contacts	Primary Contact	Update	Profile Change Request	Weaver, Weston Ross Outpatient Pharmacy Manager Uintah Basin Medical Center 4357224691-1316	Weaver, Weston Ross Outpatient Pharmacy Manager Uintah Basin Medical Center 4357224691-2054	2/14/2022 5:05 PM
Details	Last Recertification Date	Update	Recertification	8/19/2020 11:29:54 AM	8/23/2021 1:04:50 PM	8/23/2021 1:04 PM
Details	Last Recertification Date	Update	Recertification	8/29/2019 1:57:07 PM	8/19/2020 11:29:54 AM	8/19/2020 11:29 AM
Details	Last Recertification Date	Update	Recertification	8/27/2018 2:34:13 PM	8/29/2019 1:57:07 PM	8/29/2019 1:57 PM
Details	Last Recertification Date	Update	Recertification	11/6/2017 10:32:33 AM	8/27/2018 2:34:13 PM	8/27/2018 2:34 PM
Contacts	Primary Contact	Update	Recertification	Anderson, Lonnie Director of Pharmacy 4357252023	Weaver, Weston Ross Outpatient Pharmacy Manager Uintah Basin Medical Center 4357224691-1316	11/6/2017 10:32 AM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/6/2017 10:32:33 AM	11/6/2017 10:32 AM
Contacts	Authorizing Official	Update		Hales, Brent CFO 4357226164	Hales, Brent CFO Uintah Basin Medical Center 4357226164	10/26/2017 1:39 PM
Contacts	Signed By	Update		Hales, Brent CFO 4357226164	Hales, Brent CFO Uintah Basin Medical Center 4357226164	10/26/2017 1:39 PM
Contacts	Authorizing Official	Insert			Hales, Brent CFO 4357226164	8/10/2017 1:38 PM
Contacts	Signed By	Insert			Hales, Brent CFO 4357226164	8/10/2017 1:38 PM
Addresses	Main Address	Insert			205 W 300 N Roosevelt, UT 84066	8/17/2016 1:30 PM
Contacts	Primary Contact	Insert			Anderson, Lonnie Director of Pharmacy 4357252023	8/17/2016 1:30 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 1:30 PM
Details	Last Recertification Date	Update		8/22/2014 12:00:00 AM	8/10/2015 12:00:00 AM	8/10/2015 12:56 PM
Details	Last Recertification Date	Update		9/6/2013 1:21:52 PM	8/22/2014 12:00:00 AM	8/22/2014 12:48 PM
Details	Last Recertification Date	Update			9/6/2013 1:21:52 PM	9/6/2013 1:21 PM
Addresses	Billing Address	Insert			Uintah Basin Medical Center 250 W 300 N Roosevelt, UT 84066	3/11/2013 4:31 PM
Addresses	Shipping Address	Insert			Uintah Basin Medical Center 250 W 300 N Roosevelt, UT 84066	3/11/2013 4:31 PM
Details	340B ID	Update		ISJMSCH460019-01	SCH460019-01	3/11/2013 4:31 PM
Dates	Participating Approval Date	Update			3/11/2013 12:00:00 AM	3/11/2013 4:31 PM
Details	State	Update		Pending	Active	3/11/2013 4:31 PM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	3/11/2013 4:31 PM
Details	340B ID	Update		ISJMSCH463505	ISJMSCH460019-01	3/7/2013 9:58 AM
Details	340B ID	Update		JM011013A	ISJMSCH463505	2/25/2013 10:53 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	JM011013A	1/10/2013 9:40 PM
Details	Last Recertification Date	Insert				1/9/2013 11:52 AM
Details	Grant Number	Insert				1/9/2013 11:52 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	1/9/2013 11:52 AM
Details	Is Authorizing Official EHB Data	Insert				1/9/2013 11:52 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/9/2013 11:52 AM
Details	Medicare Provider Number	Insert			460019	1/9/2013 11:52 AM
Details	Entity Name	Insert			Uintah Basin Medical Center	1/9/2013 11:52 AM
Details	Program Code	Insert			SCH	1/9/2013 11:52 AM
Details	Entity Subname	Insert			Uintah Basin Medical Center Roosevelt Dialysis	1/9/2013 11:52 AM
Dates	Participating Approval Date	Insert				1/9/2013 11:52 AM
Details	State	Insert			Pending	1/9/2013 11:52 AM
Dates	Registration Date	Insert			1/9/2013 12:00:00 AM	1/9/2013 11:52 AM
Dates	Signed By Date	Insert			1/9/2013 12:00:00 AM	1/9/2013 11:52 AM
Dates	Start Date	Insert				1/9/2013 11:52 AM
Terminations	Termination Comments	Insert				1/9/2013 11:52 AM
Terminations	Termination Date	Insert				1/9/2013 11:52 AM
Terminations	Termination Effective Date	Insert				1/9/2013 11:52 AM
Terminations	Termination Reason	Insert				1/9/2013 11:52 AM