Covered Entity Details

CAH161358-00 Wayne County Hospital (Active) - information as of 4/29/2025 1:40:48 AM

Main Details

Name

Wayne County Hospital

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH161358-00

Medicare Provider Number

161358

Additional Details

Current Program Status

Active

Registration Date

1/10/2013

Participating Start Date

4/1/2013

Participating Approval Date

1/16/2013

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Wayne County Hospital
Denise Hook, CFO
(641) 872-5277

Primary Contact

Wayne County Hospital
Phillip R Masters, Pharmacist
(641) 872-5262

Addresses

Street Address

417 S East Street
Corydon, IA 50060

Billing Address
Same as Street Address

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

Wayne County Hospital
417 S East Street
Corydon, IA 50060

Shipping Address 2

Wayne County Hospital dba Your Neighborhood Pharmacy
510 E Jefferson Street
Suite A
Corydon, IA 50060

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	HY-VEE PHARMACY 1065	2001 WEST COURT		CHARITON	IA	50049	10/15/2018	01/01/2019	02/04/2021	02/04/2021
Contract Detail	HY-VEE, INC	DBA: HY-VEE PHARMACY (1089)	105 E JACKSON	CORYDON	IA	50060	07/15/2016	10/01/2016	02/04/2021	02/04/2021
Contract Detail	SHOPKO PHARMACY #2676	1901 COURT AVE		CHARITON	IA	50049	07/07/2014	10/01/2014	01/01/2019	04/09/2019
Contract Detail	SHOPKO PHARMACY #2689	201 N FILLMORE ST		MOUNT AYR	IA	50854	07/07/2014	10/01/2014	10/01/2016	10/12/2016
Contract Detail	SHOPKO PHARMACY #2705	2001 E 9TH ST		TRENTON	MO	64683	07/07/2014	10/01/2014	10/01/2016	10/12/2016
Contract Detail	WAL-MART PHARMACY 10-0834	810 SOUTH 37TH STREET		BETHANY	MO	64424	07/14/2014	10/01/2014	11/25/2016	12/01/2016
Contract Detail	WAL-MART PHARMACY 10-1491	1500 NORTH JEFFERSON		INDIANOLA	IA	50125	07/14/2014	10/01/2014	11/25/2016	12/01/2016
Contract Detail	WAL-MART PHARMACY 10-1621	23148 HWY 5		CENTERVILLE	IA	52544	07/14/2014	10/01/2014	10/26/2023	03/07/2025
Contract Detail	WAL-MART PHARMACY 10-4606	2400 COLLEGE DR.		OSCEOLA	IA	50213	07/14/2014	10/01/2014	11/25/2016	12/01/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH161358-01	Child	CAH	Wayne County Hospital	Lineville Medical Clinic	101 Main Street	Lineville	IA	Active
CAH161358-02	Child	CAH	Wayne County Hospital	South Central Iowa Medical Clinic	417 South East Street	Corydon	IA	Active
CAH161358-03	Child	CAH	Wayne County Hospital	Humeston Family Medical Clinic	109 Broad Street	Humeston	IA	Active
CAH161358-04	Child	CAH	Wayne County Hospital	Seymour Medical Clinic	515 W Wall Street	Seymour	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/26/2023 12:10:45 PM	8/19/2024 1:43:15 PM	8/19/2024 1:43 PM
Contacts	Primary Contact	Update	Change Request	Chambers, Pam Pharmacist Wayne County Hospital 6418722260-5384	Masters, Phillip R Pharmacist Wayne County Hospital 6418725262	3/8/2024 6:20 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 6:36:30 AM	8/26/2023 12:10:45 PM	8/26/2023 12:10 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 4:18:12 PM	9/7/2022 6:36:30 AM	9/7/2022 6:36 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 3:47:02 PM	8/23/2021 4:18:12 PM	8/23/2021 4:18 PM
Addresses	Shipping Address	Delete	Change Request	Wayne County Hospital dba Your Neighborhood Pharmacy 510 E Jefferson Street Corydon, IA 50060		11/16/2020 10:24 AM
Addresses	Shipping Address	Insert	Change Request		Wayne County Hospital dba Your Neighborhood Pharmacy 510 E Jefferson Street Suite A Corydon, IA 50060	11/16/2020 10:24 AM
Details	Last Recertification Date	Update	Recertification	8/27/2019 4:03:47 PM	8/26/2020 3:47:02 PM	8/26/2020 3:47 PM
Addresses	Shipping Address	Delete	Change Request	Wayne County Hospital 510 E Jefferson Street Corydon, IA 50060		8/5/2020 10:44 AM
Addresses	Shipping Address	Insert	Change Request		Wayne County Hospital dba Your Neighborhood Pharmacy 510 E Jefferson Street Corydon, IA 50060	8/5/2020 10:44 AM
Addresses	Shipping Address	Insert	Change Request		Wayne County Hospital 417 S East Street Corydon, IA 50060	7/2/2020 12:52 PM
Addresses	Shipping Address	Insert	Change Request		Wayne County Hospital 510 E Jefferson Street Corydon, IA 50060	7/2/2020 12:52 PM
Addresses	Main Address	Update	Change Request	417 S E Street Corydon, IA 50060	417 S East Street Corydon, IA 50060	1/22/2020 9:27 AM
Details	Last Recertification Date	Update	Recertification	8/21/2018 4:09:32 PM	8/27/2019 4:03:47 PM	8/27/2019 4:03 PM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Cancel Termination Request	10/22/2018 12:00:00 AM		10/17/2018 10:53 AM
Details	State	Update	OPA Cancel Termination Request	To Be Terminated	Active	10/17/2018 10:53 AM
Terminations	Termination Comments	Update	OPA Cancel Termination Request	Shop-Ko, Chariton is closing their retail pharmacy.		10/17/2018 10:53 AM
Terminations	Termination Date	Update	OPA Cancel Termination Request	1/1/2019 12:00:00 AM		10/17/2018 10:53 AM
Terminations	Termination Effective Date	Update	OPA Cancel Termination Request	10/22/2018 12:00:00 AM		10/17/2018 10:53 AM
Terminations	Termination Reason	Update	OPA Cancel Termination Request	Site closure		10/17/2018 10:53 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/22/2018 12:00:00 AM	10/15/2018 3:51 PM
Details	State	Update	Termination Request	Active	To Be Terminated	10/15/2018 3:51 PM
Terminations	Termination Comments	Update	Termination Request		Shop-Ko, Chariton is closing their retail pharmacy.	10/15/2018 3:51 PM
Terminations	Termination Date	Update	Termination Request		1/1/2019 12:00:00 AM	10/15/2018 3:51 PM
Terminations	Termination Effective Date	Update	Termination Request		10/22/2018 12:00:00 AM	10/15/2018 3:51 PM
Terminations	Termination Reason	Update	Termination Request		Site closure	10/15/2018 3:51 PM
Details	Last Recertification Date	Update	Recertification	11/8/2017 10:41:34 AM	8/21/2018 4:09:32 PM	8/21/2018 4:09 PM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/8/2017 10:41:34 AM	11/8/2017 10:41 AM
Contacts	Primary Contact	Update		Chambers, Pam Pharmacist 6418722260-5384	Chambers, Pam Pharmacist Wayne County Hospital 6418722260-5384	10/23/2017 11:32 AM
Contacts	Authorizing Official	Update		Hook, Denise CFO 6418725277	Hook, Denise CFO Wayne County Hospital 6418725277	9/25/2017 4:55 PM
Contacts	Signed By	Insert			Hook, Denise CFO 6418725277	12/1/2016 3:56 PM
Contacts	Primary Contact	Update		Chambers, Pam Pharmacist 6418722260-5384	Chambers, Pam Pharmacist 6418722260-5384	8/18/2016 2:32 PM
Contacts	Authorizing Official	Insert			Hook, Denise CFO 6418725277	8/18/2016 2:32 PM
Addresses	Main Address	Insert			417 S E Street Corydon, IA 50060	8/18/2016 2:32 PM
Details	Last Recertification Date	Update		8/27/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 2:32 PM
Details	Last Recertification Date	Update		8/19/2014 12:00:00 AM	8/27/2015 12:00:00 AM	8/27/2015 7:42 AM
Contacts	Primary Contact	Insert			Chambers, Pam Pharmacist 6418722260-5384	9/8/2014 7:46 AM
Details	Last Recertification Date	Update		9/9/2013 10:34:04 AM	8/19/2014 12:00:00 AM	8/19/2014 4:44 PM
Details	Last Recertification Date	Update			9/9/2013 10:34:04 AM	9/9/2013 10:34 AM
Details	340B ID	Update		ISDMCAH161358-00	CAH161358-00	1/16/2013 4:02 PM
Dates	Participating Approval Date	Update			1/16/2013 12:00:00 AM	1/16/2013 4:02 PM
Details	State	Update		Pending	Active	1/16/2013 4:02 PM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	1/16/2013 4:02 PM
Details	340B ID	Update		TL011013A	ISDMCAH161358-00	1/16/2013 3:26 PM
Details	340B ID	Update		ONLINE_REG	TL011013A	1/10/2013 10:37 PM
Details	Last Recertification Date	Insert				1/10/2013 1:03 PM
Details	Grant Number	Insert				1/10/2013 1:03 PM
Details	340B ID	Insert			ONLINE_REG	1/10/2013 1:03 PM
Details	Is Authorizing Official EHB Data	Insert				1/10/2013 1:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/10/2013 1:03 PM
Details	Medicare Provider Number	Insert			161358	1/10/2013 1:03 PM
Details	Entity Name	Insert			Wayne County Hospital	1/10/2013 1:03 PM
Details	Program Code	Insert			CAH	1/10/2013 1:03 PM
Details	Entity Subname	Insert				1/10/2013 1:03 PM
Dates	Participating Approval Date	Insert				1/10/2013 1:03 PM
Details	State	Insert			Pending	1/10/2013 1:03 PM
Dates	Registration Date	Insert			1/10/2013 12:00:00 AM	1/10/2013 1:03 PM
Dates	Signed By Date	Insert			1/10/2013 12:00:00 AM	1/10/2013 1:03 PM
Dates	Start Date	Insert				1/10/2013 1:03 PM
Terminations	Termination Comments	Insert				1/10/2013 1:03 PM
Terminations	Termination Date	Insert				1/10/2013 1:03 PM
Terminations	Termination Effective Date	Insert				1/10/2013 1:03 PM
Terminations	Termination Reason	Insert				1/10/2013 1:03 PM