| Addresses | Shipping Address | Update | Change Request | Prairie Parkway Pharmacy
5100 Prairie Parkway
Suite 106, IA 50613 | Prairie Parkway Pharmacy
5100 Prairie Parkway
Suite 106
Cedar Falls, IA 50613 | 3/14/2025 1:53 PM |
| Addresses | Shipping Address | Insert | Change Request | | Prairie Parkway Pharmacy
5100 Prairie Parkway
Suite 106, IA 50613 | 1/14/2025 1:16 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2023 12:05:31 PM | 8/13/2024 9:58:12 AM | 8/13/2024 9:58 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Hunter, Natalie Arlene
Director Pharmacy
Allen Memorial Hospital Corporation
3192353660 | Hunter, Natalie Arlene
VP Operations
Allen Memorial Hospital Corporation
3192353660 | 7/11/2024 3:41 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Friedly, Jennifer A
Vice President/Chief Operating Officer
Allen Memorial Hospital Corporation
3192353997 | Friedly, Jennifer A
President
Allen Memorial Hospital Corporation
3192353997 | 10/10/2023 8:52 AM |
| Details | Last Recertification Date | Update | Recertification | 9/12/2022 11:30:44 AM | 8/16/2023 12:05:31 PM | 8/16/2023 12:05 PM |
| Contacts | Authorizing Official | Update | Change Request | Delagardelle, Pamela K.
President/CEO
Allen Memorial Hospital
3192353606 | Friedly, Jennifer A
Vice President/Chief Operating Officer
Allen Memorial Hospital Corporation
3192353997 | 8/11/2023 7:17 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1336231091 (NE) | | 6/16/2023 8:32 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1336231091 (MO) | | 6/16/2023 8:32 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1336231091 (MN) | | 6/16/2023 8:32 AM |
| Addresses | Shipping Address | Delete | Recertification | Prairie Parkway Pharmacy
5100 Prairie Parkway Ste 106
Cedar Falls, IA 50613 | | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1336231091 | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | NE | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1336231091 | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MO | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1336231091 | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MN | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1336231091 | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IL | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1336231091 | 9/12/2022 11:30 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | WI | 9/12/2022 11:30 AM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2021 11:37:01 AM | 9/12/2022 11:30:44 AM | 9/12/2022 11:30 AM |
| Contacts | Primary Contact | Update | | Hunter, Natalie
Director Pharmacy
Allen Memorial Hospital Corporation
3192353660 | Hunter, Natalie Arlene
Director Pharmacy
Allen Memorial Hospital Corporation
3192353660 | 4/18/2022 1:13 PM |
| Contacts | Primary Contact | Update | Change Request | Phillips, Dave B
Director Compliance
Allen Memorial Hospital Corporation
3193697121 | Hunter, Natalie
Director Pharmacy
Allen Memorial Hospital Corporation
3192353660 | 3/1/2022 1:46 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2020 4:05:14 PM | 9/3/2021 11:37:01 AM | 9/3/2021 11:37 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1336231091 | 9/3/2020 4:05 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IA | 9/3/2020 4:05 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1336231091 ( ) | | 9/3/2020 4:05 PM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2019 5:35:52 PM | 9/3/2020 4:05:14 PM | 9/3/2020 4:05 PM |
| Addresses | Shipping Address | Delete | Change Request | United Medical Park Clinic Pharmacy
1717 West Ridgeway Ave STE 50
Waterloo, IA 50701 | | 1/14/2020 5:09 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2018 11:33:47 AM | 9/11/2019 5:35:52 PM | 9/11/2019 5:35 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Flanagan, Craig
CFO and Strategy Officer
UnityPoint Health
3192353918 | Delagardelle, Pamela K.
President/CEO
Allen Memorial Hospital
3192353606 | 10/2/2018 3:02 PM |
| Contacts | Primary Contact | Update | Recertification | STAFFORD, TORI K
EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE
Allen Memorial Hospital Corporation
3192353913 | Phillips, Dave B
Director Compliance
Allen Memorial Hospital Corporation
3193697121 | 9/7/2018 11:33 AM |
| Details | Last Recertification Date | Update | Recertification | 11/11/2017 9:23:48 AM | 9/7/2018 11:33:47 AM | 9/7/2018 11:33 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2016 12:00:00 AM | 11/11/2017 9:23:48 AM | 11/11/2017 9:23 AM |
| Contacts | Primary Contact | Update | Recertification | STAFFORD, TORI
EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE
Allen Memorial Hospital Corporation
3192353913 | STAFFORD, TORI K
EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE
Allen Memorial Hospital Corporation
3192353913 | 11/3/2017 5:06 AM |
| Contacts | Authorizing Official | Update | | Flanagan, Craig
CFO and Strategy Officer
3192353918 | Flanagan, Craig
CFO and Strategy Officer
UnityPoint Health
3192353918 | 10/29/2017 10:33 AM |
| Contacts | Primary Contact | Update | | STAFFORD, TORI
EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE
3192353913 | STAFFORD, TORI
EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE
Allen Memorial Hospital Corporation
3192353913 | 10/9/2017 12:04 AM |
| Contacts | Primary Contact | Update | | Stafford, Tori
Director of Compliance
3192353913 | STAFFORD, TORI
EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE
3192353913 | 6/15/2017 2:25 PM |
| Contacts | Authorizing Official | Insert | | | Flanagan, Craig
CFO and Strategy Officer
3192353918 | 6/15/2017 2:25 PM |
| Addresses | Main Address | Insert | | |
1825 Logan Avenue
Waterloo, IA 50703-1916 | 4/20/2017 5:03 PM |
| Addresses | Shipping Address | Insert | | | Allen Clinic Pharmacy
146 West Dale St STE 103
Waterloo, IA 50703 | 4/20/2017 5:03 PM |
| Addresses | Shipping Address | Insert | | | United Medical Park Clinic Pharmacy
1717 West Ridgeway Ave STE 50
Waterloo, IA 50701 | 4/20/2017 5:03 PM |
| Addresses | Shipping Address | Insert | | | Prairie Parkway Pharmacy
5100 Prairie Parkway Ste 106
Cedar Falls, IA 50613 | 4/20/2017 5:03 PM |
| Contacts | Signed By | Insert | | | Rasmussen, Renee A.
Senior VP of Finance/CFO
3192353918 | 4/20/2017 5:03 PM |
| Details | Last Recertification Date | Update | | 8/18/2015 12:00:00 AM | 8/26/2016 12:00:00 AM | 8/26/2016 4:09 PM |
| Details | Last Recertification Date | Update | | 8/21/2014 12:00:00 AM | 8/18/2015 12:00:00 AM | 8/18/2015 1:09 PM |
| Details | Last Recertification Date | Update | | | 8/21/2014 12:00:00 AM | 8/21/2014 1:00 PM |
| Details | State | Update | | Terminated | Active | 12/13/2013 4:37 PM |
| Dates | Start Date | Update | | 4/1/2013 12:00:00 AM | 1/1/2014 12:00:00 AM | 12/13/2013 4:37 PM |
| Terminations | Termination Date | Update | | 10/1/2013 12:00:00 AM | | 12/13/2013 4:37 PM |
| Terminations | Termination Reason | Update | | Other | | 12/13/2013 4:37 PM |
| Details | Comments Public | Insert | | | 12/13/13 enrolled 4/1/13 thru 9/30/13, not enrolled 10/1/13 thru 12/31/13 due to request of covered entity, re-instated based on on-line registration submitted in Oct. 2013 | 12/13/2013 4:37 PM |
| Contacts | Primary Contact | Insert | | | Stafford, Tori
Director of Compliance
3192353913 | 7/3/2013 11:27 AM |
| Details | State | Update | | Active | Terminated | 7/3/2013 11:27 AM |
| Terminations | Termination Date | Update | | | 10/1/2013 12:00:00 AM | 7/3/2013 11:27 AM |
| Terminations | Termination Reason | Update | | | Other | 7/3/2013 11:27 AM |
| Details | 340B ID | Update | | ISBLDSH160110 | DSH160110 | 3/8/2013 2:30 PM |
| Dates | Participating Approval Date | Update | | | 3/8/2013 12:00:00 AM | 3/8/2013 2:30 PM |
| Details | State | Update | | Pending | Active | 3/8/2013 2:30 PM |
| Dates | Start Date | Update | | | 4/1/2013 12:00:00 AM | 3/8/2013 2:30 PM |
| Details | 340B ID | Update | | BL020813 | ISBLDSH160110 | 2/27/2013 4:21 PM |
| Details | 340B ID | Update | | ONLINE_REG | BL020813 | 2/8/2013 11:02 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 1/15/2013 2:28 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 0601104 | 1/15/2013 2:28 PM |
| Medicaid Billing | Medicaid: State | Insert | | | IA | 1/15/2013 2:28 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1336231091 | 1/15/2013 2:28 PM |
| Details | Last Recertification Date | Insert | | | | 1/15/2013 2:28 PM |
| Details | Grant Number | Insert | | | | 1/15/2013 2:28 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 1/15/2013 2:28 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/15/2013 2:28 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/15/2013 2:28 PM |
| Details | Medicare Provider Number | Insert | | | 160110 | 1/15/2013 2:28 PM |
| Details | Entity Name | Insert | | | Allen Memorial Hospital Corporation | 1/15/2013 2:28 PM |
| Details | Program Code | Insert | | | DSH | 1/15/2013 2:28 PM |
| Details | Entity Subname | Insert | | | | 1/15/2013 2:28 PM |
| Dates | Participating Approval Date | Insert | | | | 1/15/2013 2:28 PM |
| Details | State | Insert | | | Pending | 1/15/2013 2:28 PM |
| Dates | Registration Date | Insert | | | 1/15/2013 12:00:00 AM | 1/15/2013 2:28 PM |
| Dates | Signed By Date | Insert | | | 1/15/2013 12:00:00 AM | 1/15/2013 2:28 PM |
| Dates | Start Date | Insert | | | | 1/15/2013 2:28 PM |
| Terminations | Termination Comments | Insert | | | | 1/15/2013 2:28 PM |
| Terminations | Termination Date | Insert | | | | 1/15/2013 2:28 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/15/2013 2:28 PM |
| Terminations | Termination Reason | Insert | | | | 1/15/2013 2:28 PM |