| Contacts | Primary Contact | Update | Group Change Request | Blalock, Bruce
Vice President
John Fitzgibbon Memorial Hospital
6608313212 | Cunningham, Cheryl Lynn
Compliance Officer
John Fitzgibbon Memorial Hospital, Inc.
6608313767 | 2/14/2025 11:58 AM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2023 12:15:49 PM | 9/3/2024 10:20:49 AM | 9/3/2024 10:20 AM |
| Details | Last Recertification Date | Update | Recertification | 9/12/2022 10:06:28 AM | 8/25/2023 12:15:49 PM | 8/25/2023 12:15 PM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 5:49:02 PM | 9/12/2022 10:06:28 AM | 9/12/2022 10:06 AM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2020 10:55:02 AM | 8/27/2021 5:49:02 PM | 8/27/2021 5:49 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 595572207 (MO) | | 6/15/2021 5:24 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1952611436 (MO) | | 6/15/2021 5:24 PM |
| Medicaid Billing | Medicaid: Number | Update | | 595572207 | 595572207 | 12/10/2020 4:18 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1952611436 ( ) | | 9/1/2020 10:55 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1952611436 | 9/1/2020 10:55 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MO | 9/1/2020 10:55 AM |
| Details | Last Recertification Date | Update | Recertification | | 9/1/2020 10:55:02 AM | 9/1/2020 10:55 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Littrell, Angy P.
CFO/COO
John Fitzgibbon Memorial Hospital
6608313251 | Littrell, Angy P.
President & CEO
John Fitzgibbon Memorial Hospital
6608313251 | 9/1/2020 10:54 AM |
| Contacts | Signed By | Update | Profile Change Request | Littrell, Angy P.
CFO/COO
John Fitzgibbon Memorial Hospital
6608313251 | Littrell, Angy P.
President & CEO
John Fitzgibbon Memorial Hospital
6608313251 | 9/1/2020 10:54 AM |
| Details | State | Update | | Approved | Active | 1/1/2020 12:04 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 9/30/2019 12:00:00 AM | | 10/23/2019 11:15 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 11/7/2018 9:42:56 AM | 10/23/2019 11:15:09 AM | 10/23/2019 11:15 AM |
| Details | State | Update | Reinstatement | Terminated | Approved | 10/23/2019 11:15 AM |
| Dates | Registration Date | Update | Reinstatement | 10/16/2018 10:18:58 AM | 10/21/2019 4:15:43 PM | 10/23/2019 11:15 AM |
| Dates | Signed By Date | Update | Reinstatement | 10/16/2018 10:19:05 AM | 10/21/2019 4:15:45 PM | 10/23/2019 11:15 AM |
| Dates | Start Date | Update | Reinstatement | 1/1/2019 12:00:00 AM | 1/1/2020 12:00:00 AM | 10/23/2019 11:15 AM |
| Terminations | Termination Comments | Update | Reinstatement | Changing to SCH status due to DSH percentage below statutory minimum. | | 10/23/2019 11:15 AM |
| Terminations | Termination Date | Update | Reinstatement | 10/1/2019 12:00:00 AM | | 10/23/2019 11:15 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 10/1/2019 12:00:00 AM | | 10/23/2019 11:15 AM |
| Terminations | Termination Reason | Update | Reinstatement | DSH percentage below statutory minimum | | 10/23/2019 11:15 AM |
| Details | Comments Public | Insert | Reinstatement | | Participated starting 1/1/2019, terminated 10/1/2019. Reinstated 1/1/2020. | 10/22/2019 1:07 PM |
| Details | State | Update | | To Be Terminated | Terminated | 10/1/2019 12:05 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | OPA Edit Termination Info | 7/19/2019 12:00:00 AM | 9/30/2019 12:00:00 AM | 7/19/2019 3:14 PM |
| Details | State | Update | OPA Edit Termination Info | Terminated | To Be Terminated | 7/19/2019 3:14 PM |
| Terminations | Termination Date | Update | OPA Edit Termination Info | 7/19/2019 12:00:00 AM | 10/1/2019 12:00:00 AM | 7/19/2019 3:14 PM |
| Terminations | Termination Effective Date | Update | OPA Edit Termination Info | 7/19/2019 12:00:00 AM | 10/1/2019 12:00:00 AM | 7/19/2019 3:14 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | OPA Edit Termination Info | 9/30/2019 12:00:00 AM | 7/19/2019 12:00:00 AM | 7/19/2019 10:28 AM |
| Details | State | Update | OPA Edit Termination Info | To Be Terminated | Terminated | 7/19/2019 10:28 AM |
| Terminations | Termination Date | Update | OPA Edit Termination Info | 10/1/2019 12:00:00 AM | 7/19/2019 12:00:00 AM | 7/19/2019 10:28 AM |
| Terminations | Termination Effective Date | Update | OPA Edit Termination Info | 10/1/2019 12:00:00 AM | 7/19/2019 12:00:00 AM | 7/19/2019 10:28 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 9/30/2019 12:00:00 AM | 7/19/2019 9:12 AM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 7/19/2019 9:12 AM |
| Terminations | Termination Comments | Update | Termination Request | | Changing to SCH status due to DSH percentage below statutory minimum. | 7/19/2019 9:12 AM |
| Terminations | Termination Date | Update | Termination Request | | 10/1/2019 12:00:00 AM | 7/19/2019 9:12 AM |
| Terminations | Termination Effective Date | Update | Termination Request | | 10/1/2019 12:00:00 AM | 7/19/2019 9:12 AM |
| Terminations | Termination Reason | Update | Termination Request | | DSH percentage below statutory minimum | 7/19/2019 9:12 AM |
| Details | State | Update | | Approved | Active | 1/1/2019 12:05 AM |
| Contacts | Signed By | Update | Reinstatement | Ott, Ronald A.
President & CEO
6608313249 | Littrell, Angy P.
CFO/COO
John Fitzgibbon Memorial Hospital
6608313251 | 11/7/2018 9:42 AM |
| Dates | Participating Approval Date | Update | Reinstatement | | 11/7/2018 9:42:56 AM | 11/7/2018 9:42 AM |
| Details | State | Update | Reinstatement | Pending | Approved | 11/7/2018 9:42 AM |
| Dates | Signed By Date | Update | Reinstatement | 10/10/2013 12:00:00 AM | 10/16/2018 10:19:05 AM | 11/7/2018 9:42 AM |
| Dates | Start Date | Update | Reinstatement | | 1/1/2019 12:00:00 AM | 11/7/2018 9:42 AM |
| Details | Comments Public | Insert | Reinstatement | | Initial start 10/1/2015, Termination 10/1/2017, Reinstate 1/1/2019 | 10/18/2018 12:01 PM |
| Details | Last Recertification Date | Update | Reinstatement | 8/23/2016 12:00:00 AM | | 10/16/2018 10:18 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 9/30/2017 12:00:00 AM | | 10/16/2018 10:18 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 11/17/2013 12:00:00 AM | | 10/16/2018 10:18 AM |
| Details | State | Update | Reinstatement | Terminated | Pending | 10/16/2018 10:18 AM |
| Dates | Registration Date | Update | Reinstatement | 10/10/2013 12:00:00 AM | 10/16/2018 10:18:58 AM | 10/16/2018 10:18 AM |
| Dates | Start Date | Update | Reinstatement | 10/1/2015 12:00:00 AM | | 10/16/2018 10:18 AM |
| Terminations | Termination Comments | Update | Reinstatement | change to SCH | | 10/16/2018 10:18 AM |
| Terminations | Termination Date | Update | Reinstatement | 10/1/2017 12:00:00 AM | | 10/16/2018 10:18 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 10/1/2017 12:00:00 AM | | 10/16/2018 10:18 AM |
| Terminations | Termination Reason | Update | Reinstatement | Change of covered entity type | | 10/16/2018 10:18 AM |
| Contacts | Authorizing Official | Update | | Littrell, Angy
CFO/COO
6608313251 | Littrell, Angy P.
CFO/COO
John Fitzgibbon Memorial Hospital
6608313251 | 10/18/2017 10:53 AM |
| Contacts | Primary Contact | Update | | Blalock, Bruce
Vice President
6608313212 | Blalock, Bruce
Vice President
John Fitzgibbon Memorial Hospital
6608313212 | 9/21/2017 11:10 AM |
| Contacts | Authorizing Official | Insert | | | Littrell, Angy
CFO/COO
6608313251 | 8/8/2017 11:30 AM |
| Contacts | Primary Contact | Insert | | | Blalock, Bruce
Vice President
6608313212 | 8/3/2017 11:11 AM |
| Contacts | Signed By | Insert | | | Ott, Ronald A.
President & CEO
6608313249 | 8/3/2017 11:11 AM |
| Addresses | Main Address | Insert | | |
420 W. Front St.
Slater, MO 65349-1328 | 8/3/2017 10:50 AM |
| Details | State | Update | | To Be Terminated | Terminated | 8/3/2017 10:50 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 9/30/2017 12:00:00 AM | 8/3/2017 10:49 AM |
| Details | State | Update | | Active | To Be Terminated | 8/3/2017 10:49 AM |
| Terminations | Termination Comments | Update | | | change to SCH | 8/3/2017 10:49 AM |
| Terminations | Termination Date | Update | | | 10/1/2017 12:00:00 AM | 8/3/2017 10:49 AM |
| Terminations | Termination Effective Date | Update | | | 10/1/2017 12:00:00 AM | 8/3/2017 10:49 AM |
| Terminations | Termination Reason | Update | | | Change of covered entity type | 8/3/2017 10:49 AM |
| Details | Last Recertification Date | Update | | | 8/23/2016 12:00:00 AM | 8/23/2016 4:11 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 8/21/2015 11:03 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 595572207 | 8/21/2015 11:03 AM |
| Medicaid Billing | Medicaid: State | Insert | | | MO | 8/21/2015 11:03 AM |
| Medicaid Billing | NPI: Number | Update | | 1730182478 | 1952611436 | 8/21/2015 11:03 AM |
| Details | Last Recertification Date | Update | | 8/7/2014 12:00:00 AM | | 8/21/2015 11:03 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | 9/30/2014 12:00:00 AM | | 8/21/2015 11:03 AM |
| Details | Medicare Provider Number | Update | | | 260142 | 8/21/2015 11:03 AM |
| Details | Entity Name | Update | | JOHN FITZGIBBON MEMORIAL HOSPITAL, INC. | JOHN FITZGIBBON MEMORIAL HOSPITAL | 8/21/2015 11:03 AM |
| Details | Entity Subname | Update | | Akeman McBurney Clinic | Akeman-McBurney Medical Clinic | 8/21/2015 11:03 AM |
| Details | State | Update | | Terminated | Active | 8/21/2015 11:03 AM |
| Dates | Start Date | Update | | 1/1/2014 12:00:00 AM | 10/1/2015 12:00:00 AM | 8/21/2015 11:03 AM |
| Terminations | Termination Comments | Update | | On Tuesday, September 30, 2014, we filed our most recent cost report. This updated report reflected a DSH percentage of 9.52%. Because this fell below the statutory minimum for participation in the 340B program, we immediately discontinued purchasing 340B drugs. | | 8/21/2015 11:03 AM |
| Terminations | Termination Date | Update | | 10/1/2014 12:00:00 AM | | 8/21/2015 11:03 AM |
| Terminations | Termination Effective Date | Update | | 10/1/2014 12:00:00 AM | | 8/21/2015 11:03 AM |
| Terminations | Termination Reason | Update | | DSH percentage below statutory minimum | | 8/21/2015 11:03 AM |
| Details | Comments Public | Insert | | | 8/21/15 Participated starting 1-1-2010, terminated 10-1-2014 through 9-30-15 due to the DSH percentage below statutory minimum, reinstated based on new registration submitted in July 2015 | 8/21/2015 11:03 AM |
| Details | Comments Public | Insert | | | 10/21/14 Provider # temporarily removed to facility re-registration as a different entity type | 10/22/2014 2:07 PM |
| Details | Medicare Provider Number | Update | | 260142 | | 10/22/2014 11:29 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 9/30/2014 12:00:00 AM | 9/30/2014 10:56 PM |
| Details | State | Update | | Active | Terminated | 9/30/2014 10:56 PM |
| Terminations | Termination Comments | Update | | | On Tuesday, September 30, 2014, we filed our most recent cost report. This updated report reflected a DSH percentage of 9.52%. Because this fell below the statutory minimum for participation in the 340B program, we immediately discontinued purchasing 340B drugs. | 9/30/2014 10:56 PM |
| Terminations | Termination Date | Update | | | 10/1/2014 12:00:00 AM | 9/30/2014 10:56 PM |
| Terminations | Termination Effective Date | Update | | | 10/1/2014 12:00:00 AM | 9/30/2014 10:56 PM |
| Terminations | Termination Reason | Update | | | DSH percentage below statutory minimum | 9/30/2014 10:56 PM |
| Details | Last Recertification Date | Update | | | 8/7/2014 12:00:00 AM | 8/7/2014 2:07 PM |
| Dates | Participating Approval Date | Update | | | 11/17/2013 12:00:00 AM | 11/17/2013 7:11 AM |
| Details | State | Update | | Pending | Active | 11/17/2013 7:11 AM |
| Dates | Start Date | Update | | | 1/1/2014 12:00:00 AM | 11/17/2013 7:11 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | DSH260142A | 11/13/2013 2:05 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1730182478 | 10/10/2013 3:33 PM |
| Details | Last Recertification Date | Insert | | | | 10/10/2013 3:33 PM |
| Details | Grant Number | Insert | | | | 10/10/2013 3:33 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 10/10/2013 3:33 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/10/2013 3:33 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/10/2013 3:33 PM |
| Details | Medicare Provider Number | Insert | | | 260142 | 10/10/2013 3:33 PM |
| Details | Entity Name | Insert | | | JOHN FITZGIBBON MEMORIAL HOSPITAL, INC. | 10/10/2013 3:33 PM |
| Details | Program Code | Insert | | | DSH | 10/10/2013 3:33 PM |
| Details | Entity Subname | Insert | | | Akeman McBurney Clinic | 10/10/2013 3:33 PM |
| Dates | Participating Approval Date | Insert | | | | 10/10/2013 3:33 PM |
| Details | State | Insert | | | Pending | 10/10/2013 3:33 PM |
| Dates | Registration Date | Insert | | | 10/10/2013 12:00:00 AM | 10/10/2013 3:33 PM |
| Dates | Signed By Date | Insert | | | 10/10/2013 12:00:00 AM | 10/10/2013 3:33 PM |
| Dates | Start Date | Insert | | | | 10/10/2013 3:33 PM |
| Terminations | Termination Comments | Insert | | | | 10/10/2013 3:33 PM |
| Terminations | Termination Date | Insert | | | | 10/10/2013 3:33 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/10/2013 3:33 PM |
| Terminations | Termination Reason | Insert | | | | 10/10/2013 3:33 PM |