| Details | State | Update | | To Be Terminated | Terminated | 4/1/2022 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | | 4/1/2022 12:00:00 AM | 1/6/2022 8:57 AM |
| Details | State | Update | Hospital Type Change Request | Active | To Be Terminated | 1/6/2022 8:57 AM |
| Terminations | Termination Date | Update | Hospital Type Change Request | | 4/1/2022 12:00:00 AM | 1/6/2022 8:57 AM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | | 4/1/2022 12:00:00 AM | 1/6/2022 8:57 AM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | | Change of covered entity type | 1/6/2022 8:57 AM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2020 8:58:39 AM | 8/16/2021 9:27:07 AM | 8/16/2021 9:27 AM |
| Contacts | Primary Contact | Update | Group Change Request | Shivers, Matthew J.
Director of Pharmacy
Great River Medical Center
3197683971 | Frigo, Steve
Director, Pharmacy
Southeast Iowa Regional Medical Center
3197683971 | 8/12/2021 11:19 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Shivers, Matthew J.
Supervisor Pharmacy Operations
Great River Medical Center
3197683981 | Shivers, Matthew J.
Director of Pharmacy
Great River Medical Center
3197683971 | 7/15/2021 12:07 PM |
| Details | Entity Name | Update | Change Request | GREAT RIVER MEDICAL CENTER | Southeast Iowa Regional Medical Center | 4/28/2021 9:30 PM |
| Details | Entity Subname | Update | Change Request | Great River Hematology & Oncology | Hematology & Oncology | 4/20/2021 11:41 AM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2019 9:32:14 AM | 8/17/2020 8:58:39 AM | 8/17/2020 8:58 AM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2018 5:07:55 PM | 8/19/2019 9:32:14 AM | 8/19/2019 9:32 AM |
| Contacts | Authorizing Official | Update | Change Request | Wenzel, Matthew John
President and CEO
Great River Health System
3197683266 | Alexander, Jeremy
CFO
Great River Health System
3197683280 | 8/15/2019 7:33 AM |
| Details | Last Recertification Date | Update | Recertification | 11/3/2017 2:26:14 PM | 9/7/2018 5:07:55 PM | 9/7/2018 5:07 PM |
| Contacts | Authorizing Official | Update | AO Change Request | SLADKY, TODD
VP & C.F.O. FINANCE
Great River Medical Center
3197683280 | Wenzel, Matthew John
President and CEO
Great River Health System
3197683266 | 9/7/2018 6:47 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2016 12:00:00 AM | 11/3/2017 2:26:14 PM | 11/3/2017 2:26 PM |
| Contacts | Primary Contact | Update | | Shivers, Matthew J.
Supervisor Pharmacy Operations
3197683981 | Shivers, Matthew J.
Supervisor Pharmacy Operations
Great River Medical Center
3197683981 | 10/6/2017 9:21 AM |
| Contacts | Authorizing Official | Update | | SLADKY, TODD
VP & C.F.O. FINANCE
3197683280 | SLADKY, TODD
VP & C.F.O. FINANCE
Great River Medical Center
3197683280 | 10/2/2017 3:11 PM |
| Contacts | Signed By | Update | | SLADKY, TODD
VP & C.F.O. FINANCE
3197683280 | SLADKY, TODD
VP & C.F.O. FINANCE
Great River Medical Center
3197683280 | 10/2/2017 3:11 PM |
| Contacts | Primary Contact | Update | | Good, Phillip
Reimbursement Coordinator
3197683606 | Shivers, Matthew J.
Supervisor Pharmacy Operations
3197683981 | 4/19/2017 3:32 PM |
| Contacts | Authorizing Official | Insert | | | SLADKY, TODD
VP & C.F.O. FINANCE
3197683280 | 4/19/2017 3:32 PM |
| Contacts | Signed By | Insert | | | SLADKY, TODD
VP & C.F.O. FINANCE
3197683280 | 4/19/2017 3:32 PM |
| Addresses | Main Address | Insert | | |
1225 S Gear Avenue
West Burlington, IA 52655 | 4/19/2017 3:31 PM |
| Contacts | Primary Contact | Insert | | | Good, Phillip
Reimbursement Coordinator
3197683606 | 8/16/2016 11:48 AM |
| Details | Last Recertification Date | Update | | 8/20/2015 12:00:00 AM | 8/16/2016 12:00:00 AM | 8/16/2016 11:48 AM |
| Details | Last Recertification Date | Update | | | 8/20/2015 12:00:00 AM | 8/20/2015 10:44 AM |
| Dates | Participating Approval Date | Update | | | 5/15/2015 12:00:00 AM | 5/15/2015 11:28 AM |
| Details | State | Update | | Pending | Active | 5/15/2015 11:28 AM |
| Dates | Start Date | Update | | | 7/1/2015 12:00:00 AM | 5/15/2015 11:28 AM |
| Details | Entity Subname | Update | | Great River Hematology & Oncology / Great River Hematology & Oncology | Great River Hematology & Oncology | 5/15/2015 11:23 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_51393 | RRC160057-04 | 5/7/2015 12:37 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_51393 | 4/14/2015 6:27 AM |
| Details | Last Recertification Date | Insert | | | | 4/14/2015 6:27 AM |
| Details | Grant Number | Insert | | | | 4/14/2015 6:27 AM |
| Details | 340B ID | Insert | | | | 4/14/2015 6:27 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/14/2015 6:27 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/14/2015 6:27 AM |
| Details | Medicare Provider Number | Insert | | | 160057 | 4/14/2015 6:27 AM |
| Details | Entity Name | Insert | | | GREAT RIVER MEDICAL CENTER | 4/14/2015 6:27 AM |
| Details | Program Code | Insert | | | RRC | 4/14/2015 6:27 AM |
| Details | Entity Subname | Insert | | | Great River Hematology & Oncology / Great River Hematology & Oncology | 4/14/2015 6:27 AM |
| Dates | Participating Approval Date | Insert | | | | 4/14/2015 6:27 AM |
| Details | State | Insert | | | Pending | 4/14/2015 6:27 AM |
| Dates | Registration Date | Insert | | | 4/14/2015 12:00:00 AM | 4/14/2015 6:27 AM |
| Dates | Signed By Date | Insert | | | 4/14/2015 12:00:00 AM | 4/14/2015 6:27 AM |
| Dates | Start Date | Insert | | | | 4/14/2015 6:27 AM |
| Terminations | Termination Comments | Insert | | | | 4/14/2015 6:27 AM |
| Terminations | Termination Date | Insert | | | | 4/14/2015 6:27 AM |
| Terminations | Termination Effective Date | Insert | | | | 4/14/2015 6:27 AM |
| Terminations | Termination Reason | Insert | | | | 4/14/2015 6:27 AM |