Covered Entity Details

DSH260195AA CITIZENS MEMORIAL HOSPITAL DISTRICT (Active) - information as of 4/25/2025 5:37:07 PM

Main Details

Name

CITIZENS MEMORIAL HOSPITAL DISTRICT

Subdivision Name

Bolivar Family Care Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260195AA

Medicare Provider Number

260195

Outpatient Facility Provider Number

268694

Additional Details

Current Program Status

Active

Registration Date

10/14/2014

Participating Start Date

4/1/2022

Participating Approval Date

12/9/2014

Last Recertification Date

8/18/2024

Contacts

Authorizing Official

Citizens Memorial Hospital
Renee Marie Meyer, Chief Financial Officer
(417) 328-6258

Primary Contact

Citizens Memorial Hospital District
Tim Wolters, Director of Reimbursement
(417) 328-7286

Addresses

Street Address

1240 North Butterfield
Bolivar, MO 65613

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?
Yes

State	Medicaid Number	NPI Number
MO	596054304	1063588960

Shipping Addresses

Shipping Address 1

Citizens Memorial Hospital District
1500 North Oakland
Bolivar, MO 65613

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
DSH260195AA	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Bolivar Family Care Center	1240 North Butterfield	Bolivar	MO	Active
DSH260195AB	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Osceola Medical Center	855 Arduser Drive	Osceola	MO	Active
DSH260195AC	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH St. Clair County Ambulance Service	700 Giesler Road	Osceola	MO	Active
DSH260195AD	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Cedar County Ambulance Service - El Dorado Springs	722 East Highway 54	El Dorado Springs	MO	ToBeTerminated
DSH260195AE	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Cedar County Ambulance Service - Stockton	816 West Highway 32	Stockton	MO	ToBeTerminated
DSH260195AF	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Hickory County Ambulance Service	18572 First Street	Hermitage	MO	Active
DSH260195AG	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Polk County Ambulance Service	1551 North Oakland	Bolivar	MO	Active
DSH260195AH	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	El Dorado Springs Medical Center	322 East Hospital Road	El Dorado Springs	MO	Active
DSH260195AJ	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Citizens Memorial Hospital District - CMH Gastroenterology Clinic	1155 West Parkview Street	Bolivar	MO	Active
DSH260195AK	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Willard Medical Center and Walk In Clinic - CMH Willard Medical Center and Walk In Clinic	502 S. Miller Road	Willard	MO	Active
DSH260195AL	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Dermatology Clinic - CMH Dermatology Clinic	1125 N. Butterfield Road	Bolivar	MO	Active
DSH260195AM	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Medication Management Clinic	1100 S Springfield Ave	Bolivar	MO	Active
DSH260195AN	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Health & Wellness Clinic	2520 S Springfield Ave	Bolivar	MO	Active
DSH260195AP	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Douglas Medical Center Imaging - CMH Imaging Center	1155 West Parkview Street, Suite 1E	Bolivar	MO	Approved
DSH260195B	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	AMBULATORY SURGERY CENTER	1155 WEST PARKVIEW	BOLIVAR	MO	Active
DSH260195C	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Dade County Family Medical Center	105 North Grand, Suite 2	Greenfield	MO	Active
DSH260195D	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Stockton Family Medical Center	1521 South 3rd Street	Stockton	MO	Active
DSH260195F	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Humansville Family Medical Center	201 South Arthur	Humansville	MO	Active
DSH260195G	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Ash Grove Family Medical Center	500 North Medical Drive	Ash Grove	MO	Active
DSH260195H	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Dallas County Family Medical Center	201 South Ash	Buffalo	MO	Active
DSH260195J	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Walk-In Clinic	2230 South Springfield, Suite H-J	Bolivar	MO	Active
DSH260195K	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Pleasant Hope Family Medical Center	209 South Main	Pleasant Hope	MO	Active
DSH260195L	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Butterfield Park Medical Center	1300 North Oakland	Bolivar	MO	Active
DSH260195M	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH OB/GYN and Pediatric Clinic	1195 North Oakland	Bolivar	MO	Active
DSH260195N	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Institute of Pain Management	1155 West Parkview Street, Suite 1C	Bolivar	MO	Active
DSH260195P	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Infusion/Medical Oncology	1155 West Parkview Street, Suite 2M	Bolivar	MO	Active
DSH260195Q	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Wound and Hyperbaric Center	1155 West Parkview Street, Suite 1G	Bolivar	MO	Terminated
DSH260195R	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Southside Medical Center	1120 South Springfield Avenue	Bolivar	MO	Active
DSH260195S	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Pulmonology Clinic	1165 North Butterfield Road	Bolivar	MO	Active
DSH260195T	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Urological Clinic	1155 West Parkview Street, Suite 2C	Bolivar	MO	Active
DSH260195U	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Rheumatology and Osteoporosis Center	1155 West Parkview Street, Suite 2K	Bolivar	MO	Active
DSH260195V	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Heart Institute Clinic	1500 North Oakland	Bolivar	MO	Active
DSH260195W	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Neurology Clinic	1245 North Butterfield	Bolivar	MO	Active
DSH260195X	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH General Surgery Clinic	1155 West Parkview Street, Suite 1F	Bolivar	MO	Active
DSH260195Y	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Infectious Disease Clinic	1155 West Parkview Street, Suite 1F	Bolivar	MO	Active
DSH260195Z	Child	DSH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Specialty Clinic	1155 West Parkview Street, Suite 2J	Bolivar	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/16/2023 6:04:25 PM	8/18/2024 12:43:26 PM	8/18/2024 12:43 PM
Addresses	Shipping Address	Insert	Group Change Request		Citizens Memorial Hospital District 1500 North Oakland Bolivar, MO 65613	1/8/2024 2:15 PM
Details	Last Recertification Date	Update	Recertification	8/27/2022 3:03:23 PM	8/16/2023 6:04:25 PM	8/16/2023 6:04 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/11/2023 11:36 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		596054304	4/11/2023 11:36 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	4/11/2023 11:36 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1063588960	4/11/2023 11:36 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	4/11/2023 11:36 AM
Details	Last Recertification Date	Update	Recertification	8/17/2021 2:29:07 PM	8/27/2022 3:03:23 PM	8/27/2022 3:03 PM
Details	State	Update		Approved	Active	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	COVID-19 Reinstatement	11/1/2021 12:00:00 AM		3/25/2022 5:33 PM
Details	State	Update	COVID-19 Reinstatement	Terminated	Approved	3/25/2022 5:33 PM
Dates	Start Date	Update	COVID-19 Reinstatement	1/1/2015 12:00:00 AM	4/1/2022 12:00:00 AM	3/25/2022 5:33 PM
Terminations	Termination Date	Update	COVID-19 Reinstatement	11/1/2021 12:00:00 AM		3/25/2022 5:33 PM
Terminations	Termination Effective Date	Update	COVID-19 Reinstatement	11/1/2021 12:00:00 AM		3/25/2022 5:33 PM
Terminations	Termination Reason	Update	COVID-19 Reinstatement	Change of hospital entity type		3/25/2022 5:33 PM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Edit Termination Info	1/1/2022 12:00:00 AM	11/1/2021 12:00:00 AM	11/10/2021 9:21 AM
Details	State	Update	OPA Edit Termination Info	To Be Terminated	Terminated	11/10/2021 9:21 AM
Terminations	Termination Date	Update	OPA Edit Termination Info	1/1/2022 12:00:00 AM	11/1/2021 12:00:00 AM	11/10/2021 9:21 AM
Terminations	Termination Effective Date	Update	OPA Edit Termination Info	1/1/2022 12:00:00 AM	11/1/2021 12:00:00 AM	11/10/2021 9:21 AM
Terminations	Termination Reason	Update	OPA Edit Termination Info	Change of covered entity type	Change of hospital entity type	11/10/2021 9:21 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		1/1/2022 12:00:00 AM	11/1/2021 8:09 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	11/1/2021 8:09 AM
Terminations	Termination Date	Update	Hospital Type Change Request		1/1/2022 12:00:00 AM	11/1/2021 8:09 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		1/1/2022 12:00:00 AM	11/1/2021 8:09 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	11/1/2021 8:09 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	596054304 (MO)		9/14/2021 5:55 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1063588960 (MO)		9/14/2021 5:55 PM
Details	Last Recertification Date	Update	Recertification	8/25/2020 9:46:31 AM	8/17/2021 2:29:07 PM	8/17/2021 2:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/31/2020 11:39 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		596054304	12/31/2020 11:39 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	12/31/2020 11:39 AM
Medicaid Billing	NPI: State	Update	Recertification		MO	8/25/2020 9:46 AM
Details	Last Recertification Date	Update	Recertification	8/24/2019 11:11:10 AM	8/25/2020 9:46:31 AM	8/25/2020 9:46 AM
Contacts	Authorizing Official	Update	Profile Change Request	Meyer, Renee Marie Chief Fnancial Officer Citizens Memorial Hospital 4173286258	Meyer, Renee Marie Chief Financial Officer Citizens Memorial Hospital 4173286258	1/9/2020 12:32 PM
Contacts	Authorizing Official	Update	AO Change Request	Fulbright, Gary Dene Chief Financial Officer Citizens Memorial Hospital District 4173286402	Meyer, Renee Marie Chief Fnancial Officer Citizens Memorial Hospital 4173286258	1/9/2020 9:37 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 11:32:37 AM	8/24/2019 11:11:10 AM	8/24/2019 11:11 AM
Details	Last Recertification Date	Update	Recertification	12/4/2017 6:12:57 PM	8/22/2018 11:32:37 AM	8/22/2018 11:32 AM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	12/4/2017 6:12:57 PM	12/4/2017 6:12 PM
Contacts	Authorizing Official	Insert	AO Change Request		Fulbright, Gary Dene Chief Financial Officer Citizens Memorial Hospital District 4173286402	10/5/2017 1:04 PM
Contacts	Primary Contact	Update		Wolters, Tim Director of Reimbursement 4173287286	Wolters, Tim Director of Reimbursement Citizens Memorial Hospital District 4173287286	9/28/2017 2:04 PM
Contacts	Signed By	Insert			Babb, Donald J. Chief Executive Officer 4173286501	8/10/2017 10:05 AM
Contacts	Primary Contact	Insert			Wolters, Tim Director of Reimbursement 4173287286	7/31/2017 7:18 PM
Addresses	Main Address	Insert			1240 North Butterfield Bolivar, MO 65613	7/31/2017 7:18 PM
Details	Last Recertification Date	Update		8/10/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 5:31 PM
Details	Last Recertification Date	Update			8/10/2015 12:00:00 AM	8/10/2015 5:13 PM
Dates	Participating Approval Date	Update			12/9/2014 12:00:00 AM	12/9/2014 10:34 AM
Details	State	Update		Pending	Active	12/9/2014 10:34 AM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	12/9/2014 10:34 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_47401	DSH260195AA	11/3/2014 12:57 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_47401	10/14/2014 4:44 PM
Medicaid Billing	NPI: Number	Insert			1063588960	10/14/2014 4:44 PM
Details	Last Recertification Date	Insert				10/14/2014 4:44 PM
Details	Grant Number	Insert				10/14/2014 4:44 PM
Details	340B ID	Insert				10/14/2014 4:44 PM
Details	Is Authorizing Official EHB Data	Insert				10/14/2014 4:44 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2014 4:44 PM
Details	Medicare Provider Number	Insert			260195	10/14/2014 4:44 PM
Details	Entity Name	Insert			CITIZENS MEMORIAL HOSPITAL DISTRICT	10/14/2014 4:44 PM
Details	Program Code	Insert			DSH	10/14/2014 4:44 PM
Details	Entity Subname	Insert			Bolivar Family Care Center	10/14/2014 4:44 PM
Dates	Participating Approval Date	Insert				10/14/2014 4:44 PM
Details	State	Insert			Pending	10/14/2014 4:44 PM
Dates	Registration Date	Insert			10/14/2014 12:00:00 AM	10/14/2014 4:44 PM
Dates	Signed By Date	Insert			10/14/2014 12:00:00 AM	10/14/2014 4:44 PM
Dates	Start Date	Insert				10/14/2014 4:44 PM
Terminations	Termination Comments	Insert				10/14/2014 4:44 PM
Terminations	Termination Date	Insert				10/14/2014 4:44 PM
Terminations	Termination Effective Date	Insert				10/14/2014 4:44 PM
Terminations	Termination Reason	Insert				10/14/2014 4:44 PM