Covered Entity Details

CAH261338-02 MERCY HOSPITAL MCCCUNE BROOKS (Terminated) - information as of 6/14/2025 10:04:37 AM

Main Details

Name

MERCY HOSPITAL MCCCUNE BROOKS

Subdivision Name

MERCY HOSPITAL CARTHAGE / Mercy Physicians for Womens Health

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH261338-02

Medicare Provider Number

261338

Outpatient Facility Provider Number

268688

Additional Details

Current Program Status

Terminated

Registration Date

4/9/2015

Participating Start Date

7/1/2015

Participating Approval Date

5/21/2015

Last Recertification Date

8/17/2015

Termination Date
Termination Reason

10/1/2015
Other

Contacts

Authorizing Official

Mercy
Thomas P Mathews, Vice President Finance
(417) 556-2459

Primary Contact

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

Addresses

Street Address

1515 HAZEL ST SUITE 101
MERCY PHYSICIANS FOR WOMENS HEALTH
CARTHAGE, MO 64836-2842

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	1992074959
		1992074959

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
CAH261338-01	Child	CAH	MERCY HOSPITAL MCCCUNE BROOKS	MERCY HOSPITAL CARTHAGE / Mercy Carthage Pediatrics	1911 BUENTA VISTA	CARTHAGE	MO	Terminated
CAH261338-02	Child	CAH	MERCY HOSPITAL MCCCUNE BROOKS	MERCY HOSPITAL CARTHAGE / Mercy Physicians for Womens Health	1515 HAZEL ST SUITE 101	CARTHAGE	MO	Terminated
CAH261338-03	Child	CAH	MERCY HOSPITAL MCCCUNE BROOKS	MERCY PRIMARY CARE / Mercy Carthage Primary Care	1515 HAZEL STREET SUITE 201	CARTHAGE	MO	Terminated
CAH261338-04	Child	CAH	MERCY HOSPITAL CARTHAGE	MERCY HOSPITAL CARTHAGE - Neurology Clinic	3125 DR RUSSELL SMITH WAY	CARTHAGE	MO	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Watson, Robert Scott Administrator Mercy Hospital Carthage 4173592653	Mathews, Thomas P Vice President Finance Mercy 4175562459	6/25/2020 9:24 AM
Contacts	Authorizing Official	Update	Change Request	Pulsipher, Gary W. President Mercy Hospital Joplin 4175562200	Watson, Robert Scott Administrator Mercy Hospital Carthage 4173592653	7/30/2019 9:56 AM
Contacts	Authorizing Official	Insert	Change Request		Pulsipher, Gary W. President Mercy Hospital Joplin 4175562200	10/4/2017 9:12 AM
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	Signed By	Insert			Hunter, Shelly Chief Financial Officer 4175562459	8/29/2016 12:03 PM
Details	Last Recertification Date	Update			8/17/2015 12:00:00 AM	8/17/2015 8:42 AM
Dates	Last Date That 340B Drugs Purchased	Update			7/1/2015 12:00:00 AM	8/17/2015 8:42 AM
Details	State	Update		Active	Terminated	8/17/2015 8:42 AM
Terminations	Termination Comments	Update			This is an offsite location of the main hospital that functions independently from medication purchasing. We are choosing to decertify this location of the hospital. No 340B purchases have been made for this location.	8/17/2015 8:42 AM
Terminations	Termination Date	Update			10/1/2015 12:00:00 AM	8/17/2015 8:42 AM
Terminations	Termination Effective Date	Update			7/1/2015 12:00:00 AM	8/17/2015 8:42 AM
Terminations	Termination Reason	Update			Other	8/17/2015 8:42 AM
Addresses	Main Address	Insert			1515 HAZEL ST SUITE 101 MERCY PHYSICIANS FOR WOMENS HEALTH CARTHAGE, MO 64836-2842	8/17/2015 8:42 AM
Details	Medicare Provider Number	Update		260228	261338	5/22/2015 10:26 AM
Details	340B ID	Update		CAH260228-02	CAH261338-02	5/21/2015 4:05 PM
Dates	Participating Approval Date	Update			5/21/2015 12:00:00 AM	5/21/2015 4:05 PM
Details	State	Update		Pending	Active	5/21/2015 4:05 PM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	5/21/2015 4:05 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_50987	CAH260228-02	4/21/2015 9:35 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_50987	4/9/2015 4:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/9/2015 4:08 PM
Medicaid Billing	Medicaid: Number	Insert			1992074959	4/9/2015 4:08 PM
Medicaid Billing	Medicaid: State	Insert			MO	4/9/2015 4:08 PM
Medicaid Billing	NPI: Number	Insert			1992074959	4/9/2015 4:08 PM
Details	Last Recertification Date	Insert				4/9/2015 4:08 PM
Details	Grant Number	Insert				4/9/2015 4:08 PM
Details	340B ID	Insert				4/9/2015 4:08 PM
Details	Is Authorizing Official EHB Data	Insert				4/9/2015 4:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/9/2015 4:08 PM
Details	Medicare Provider Number	Insert			260228	4/9/2015 4:08 PM
Details	Entity Name	Insert			MERCY HOSPITAL MCCCUNE BROOKS	4/9/2015 4:08 PM
Details	Program Code	Insert			CAH	4/9/2015 4:08 PM
Details	Entity Subname	Insert			MERCY HOSPITAL CARTHAGE / Mercy Physicians for Womens Health	4/9/2015 4:08 PM
Dates	Participating Approval Date	Insert				4/9/2015 4:08 PM
Details	State	Insert			Pending	4/9/2015 4:08 PM
Dates	Registration Date	Insert			4/9/2015 12:00:00 AM	4/9/2015 4:08 PM
Dates	Signed By Date	Insert			4/9/2015 12:00:00 AM	4/9/2015 4:08 PM
Dates	Start Date	Insert				4/9/2015 4:08 PM
Terminations	Termination Comments	Insert				4/9/2015 4:08 PM
Terminations	Termination Date	Insert				4/9/2015 4:08 PM
Terminations	Termination Effective Date	Insert				4/9/2015 4:08 PM
Terminations	Termination Reason	Insert				4/9/2015 4:08 PM