Covered Entity Details

DSH260059J Mercy Hospital Lebanon (Active) - information as of 5/27/2025 2:41:14 PM

Main Details

Name

Mercy Hospital Lebanon

Subdivision Name

Lebanon Hospital / CT Scan Rolla

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260059J

Medicare Provider Number

260059

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/8/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/4/2015

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Mercy Hospital Springfield
William J Roberts, Vice President Finance
(417) 820-7363

Primary Contact

Mercy Shared Services
Mike Loftus, Director-Hospital Pharmacy
(417) 820-3487

Addresses

Street Address

1605 MARTIN SPRINGS DRIVE
ROLLA IMAGING SERVICES
ROLLA, MO 65401

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	010492007	1447284898,1740413988

Shipping Addresses

Same as Street Address

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
DSH260059A	Child	DSH	Mercy Hospital Lebanon	Outpatient Services	100 Hospital Drive	LEBANON	MO	Active
DSH260059B	Child	DSH	Mercy Hospital Lebanon	MERCY ONCOLOGY INFUSION CENTER	1605 MARTIN SPRINGS DRIVE	ROLLA	MO	Active
DSH260059C	Child	DSH	Mercy Hospital Lebanon	MERCY SURGERY CENTER	1605 MARTIN SPRINGS DRIVE	ROLLA	MO	Active
DSH260059F	Child	DSH	Mercy Hospital Lebanon	MERCY HOSPITAL LEBANON / Lebanon Hospital Rolla Nuclear Medicine	1605 MARTIN SPRINGS DRIVE	ROLLA	MO	Active
DSH260059G	Child	DSH	Mercy Hospital Lebanon	Lebanon Hospital / MRI Rolla	1605 MARTIN SPRINGS DRIVE	ROLLA	MO	Active
DSH260059H	Child	DSH	Mercy Hospital Lebanon	Lebanon Hospital / Imaging Services Rolla	1605 MARTIN SPRINGS DRIVE	ROLLA	MO	Active
DSH260059J	Child	DSH	Mercy Hospital Lebanon	Lebanon Hospital / CT Scan Rolla	1605 MARTIN SPRINGS DRIVE	ROLLA	MO	Active
DSH260059K	Child	DSH	Mercy Hospital Lebanon	Lebanon Hospital / Rolla Breast Center	1605 MARTIN SPRINGS DRIVE	ROLLA	MO	Active
DSH260059L	Child	DSH	Mercy Hospital Lebanon	MERCY HOSPITAL LEBANON - Rolla Pain Management	1605 MARTIN SPRINGS DR	ROLLA	MO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	Loftus, Mike Director-Pharmacy Services Mercy 4178203487	Loftus, Mike Director-Hospital Pharmacy Mercy Shared Services 4178203487	8/20/2024 9:28 AM
Details	Last Recertification Date	Update	Recertification	8/21/2023 4:58:48 PM	8/20/2024 9:28:16 AM	8/20/2024 9:28 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 6:15:01 PM	8/21/2023 4:58:48 PM	8/21/2023 4:58 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 11:40:57 AM	9/1/2022 6:15:01 PM	9/1/2022 6:15 PM
Details	Last Recertification Date	Update	Recertification	8/27/2020 5:51:50 AM	8/23/2021 11:40:57 AM	8/23/2021 11:40 AM
Addresses	Main Address	Update	Recertification	1605 MARTIN SPRINGS DRIVE SUITE 110 ROLLA IMAGING SERVICES ROLLA, MO 65401	1605 MARTIN SPRINGS DRIVE ROLLA IMAGING SERVICES ROLLA, MO 65401	8/27/2020 5:51 AM
Medicaid Billing	NPI: State	Update	Recertification		MO	8/27/2020 5:51 AM
Medicaid Billing	NPI: State	Update	Recertification		MO	8/27/2020 5:51 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 5:30:53 PM	8/27/2020 5:51:50 AM	8/27/2020 5:51 AM
Contacts	Authorizing Official	Update	Change Request	Hubbard, Brent President-COO Mercy 4178209606	Roberts, William J Vice President Finance Mercy Hospital Springfield 4178207363	6/24/2020 8:48 AM
Contacts	Authorizing Official	Update	Change Request	Vincent, Jenine Vice President-Operations Mercy 4178206747	Hubbard, Brent President-COO Mercy 4178209606	3/13/2020 1:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1740413988	1/26/2020 9:20 PM
Contacts	Authorizing Official	Update	Change Request	Childers, Scott Administrator Mercy Hospital Lebanon 4175336012	Vincent, Jenine Vice President-Operations Mercy 4178206747	1/7/2020 2:51 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 12:54:42 PM	8/21/2019 5:30:53 PM	8/21/2019 5:30 PM
Contacts	Authorizing Official	Update	Change Request	HOBAN, DOUGLAS CHIEF FINANCIAL OFFICER Mercy Hospital Lebanon 4175336048	Childers, Scott Administrator Mercy Hospital Lebanon 4175336012	5/6/2019 7:46 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1447284898	4/11/2019 10:23 AM
Addresses	Main Address	Update	Recertification	1605 MARTIN SPRINGS DRIVE SUITE 110 ROLLA IMAGING SERVICES ROLLA, MO 65536-9210	1605 MARTIN SPRINGS DRIVE SUITE 110 ROLLA IMAGING SERVICES ROLLA, MO 65401	8/28/2018 12:54 PM
Details	Last Recertification Date	Update	Recertification	11/28/2017 9:17:43 AM	8/28/2018 12:54:42 PM	8/28/2018 12:54 PM
Details	Entity Name	Update	Recertification	MERCY HOSPITAL LEBANON	Mercy Hospital Lebanon	11/29/2017 7:37 PM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/28/2017 9:17:43 AM	11/28/2017 9:17 AM
Contacts	Authorizing Official	Update		HOBAN, DOUGLAS CHIEF FINANCIAL OFFICER 4175336048	HOBAN, DOUGLAS CHIEF FINANCIAL OFFICER Mercy Hospital Lebanon 4175336048	10/10/2017 4:05 PM
Contacts	Signed By	Update		HOBAN, DOUGLAS CHIEF FINANCIAL OFFICER 4175336048	HOBAN, DOUGLAS CHIEF FINANCIAL OFFICER Mercy Hospital Lebanon 4175336048	10/10/2017 4:05 PM
Contacts	Primary Contact	Update		Loftus, Mike Director-Pharmacy Services 4178203487	Loftus, Mike Director-Pharmacy Services Mercy 4178203487	9/27/2017 3:06 PM
Contacts	Primary Contact	Insert			Loftus, Mike Director-Pharmacy Services 4178203487	8/8/2017 10:51 AM
Contacts	Authorizing Official	Insert			HOBAN, DOUGLAS CHIEF FINANCIAL OFFICER 4175336048	8/8/2017 10:51 AM
Contacts	Signed By	Insert			HOBAN, DOUGLAS CHIEF FINANCIAL OFFICER 4175336048	8/8/2017 10:51 AM
Addresses	Main Address	Insert			1605 MARTIN SPRINGS DRIVE SUITE 110 ROLLA IMAGING SERVICES ROLLA, MO 65536-9210	8/15/2016 10:12 AM
Details	Last Recertification Date	Update		8/14/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/13/2016 3:16 PM
Medicaid Billing	Medicaid: Number	Insert			010492007	7/13/2016 3:16 PM
Medicaid Billing	Medicaid: State	Insert			MO	7/13/2016 3:16 PM
Details	Last Recertification Date	Update			8/14/2015 12:00:00 AM	8/14/2015 7:46 AM
Dates	Participating Approval Date	Update			3/4/2015 12:00:00 AM	3/4/2015 6:51 PM
Details	State	Update		Pending	Active	3/4/2015 6:51 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/4/2015 6:51 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_48468	DSH260059J	2/4/2015 11:33 AM
Details	Entity Subname	Update		MERCY HOSPITAL LEBANON / Lebanon Hospital CT Scan Rolla	Lebanon Hospital / CT Scan Rolla	2/4/2015 11:33 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_48468	1/8/2015 4:40 PM
Details	Last Recertification Date	Insert				1/8/2015 4:40 PM
Details	Grant Number	Insert				1/8/2015 4:40 PM
Details	340B ID	Insert				1/8/2015 4:40 PM
Details	Is Authorizing Official EHB Data	Insert				1/8/2015 4:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/8/2015 4:40 PM
Details	Medicare Provider Number	Insert			260059	1/8/2015 4:40 PM
Details	Entity Name	Insert			MERCY HOSPITAL LEBANON	1/8/2015 4:40 PM
Details	Program Code	Insert			DSH	1/8/2015 4:40 PM
Details	Entity Subname	Insert			MERCY HOSPITAL LEBANON / Lebanon Hospital CT Scan Rolla	1/8/2015 4:40 PM
Dates	Participating Approval Date	Insert				1/8/2015 4:40 PM
Details	State	Insert			Pending	1/8/2015 4:40 PM
Dates	Registration Date	Insert			1/8/2015 12:00:00 AM	1/8/2015 4:40 PM
Dates	Signed By Date	Insert			1/8/2015 12:00:00 AM	1/8/2015 4:40 PM
Dates	Start Date	Insert				1/8/2015 4:40 PM
Terminations	Termination Comments	Insert				1/8/2015 4:40 PM
Terminations	Termination Date	Insert				1/8/2015 4:40 PM
Terminations	Termination Effective Date	Insert				1/8/2015 4:40 PM
Terminations	Termination Reason	Insert				1/8/2015 4:40 PM