Covered Entity Details

CAH031311-01 Winslow Memorial Hospital dba Little Colorado Medical Center (Active) - information as of 4/23/2025 10:51:39 PM

Main Details

Name

Winslow Memorial Hospital dba Little Colorado Medical Center

Subdivision Name

WINSLOW MEMORIAL HOSPITAL INC. / little colorado physician clinic family practice

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH031311-01

Medicare Provider Number

031311

Outpatient Facility Provider Number

024294

Additional Details

Current Program Status

Active

Registration Date

10/7/2016

Participating Start Date

1/1/2017

Participating Approval Date

10/17/2016

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

LITTLE COLORADO MEDICAL CENTER
Doug Umlah, Chief Ancillary Officer
(928) 289-6360

Primary Contact

LITTLE COLORADO MEDICAL CENTER
Loren Trager, Director of Pharmacy
(928) 289-6325

Addresses

Street Address

200 E LEE ST
LITTLE COLORADO PHYSICIANS OFFICE
WINSLOW, AZ 86047-2063

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
AZ	383126	1144710203

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
CAH031311-01	Child	CAH	Winslow Memorial Hospital dba Little Colorado Medical Center	WINSLOW MEMORIAL HOSPITAL INC. / little colorado physician clinic family practice	200 E LEE ST	WINSLOW	AZ	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/21/2023 11:31:00 AM	8/14/2024 9:57:04 AM	8/14/2024 9:57 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 11:05:45 AM	8/21/2023 11:31:00 AM	8/21/2023 11:31 AM
Contacts	Authorizing Official	Update	Change Request	Black, Ross COO Little Colorado Medical Center 9282896345	Umlah, Doug Chief Ancillary Officer LITTLE COLORADO MEDICAL CENTER 9282896360	7/5/2023 11:10 AM
Details	Last Recertification Date	Update	Recertification	8/17/2021 12:17:31 PM	8/24/2022 11:05:45 AM	8/24/2022 11:05 AM
Contacts	Primary Contact	Update	PC Change Request	Roman, Michael Director of Pharmacy Little Colorado Medical Center 9282896325	Trager, Loren Director of Pharmacy LITTLE COLORADO MEDICAL CENTER 9282896325	4/6/2022 12:50 PM
Details	Last Recertification Date	Update	Recertification	8/31/2020 3:44:36 PM	8/17/2021 12:17:31 PM	8/17/2021 12:17 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1144710203 ( )		8/31/2020 3:44 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1144710203	8/31/2020 3:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/31/2020 3:44 PM
Details	Last Recertification Date	Update	Recertification	8/20/2019 12:59:34 PM	8/31/2020 3:44:36 PM	8/31/2020 3:44 PM
Details	Last Recertification Date	Update	Recertification	8/16/2018 12:01:51 PM	8/20/2019 12:59:34 PM	8/20/2019 12:59 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	020389	383126	6/14/2019 3:04 PM
Medicaid Billing	NPI: Number	Update	Change Request	1477653889	1144710203	6/14/2019 3:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1477653889 (AZ)		5/30/2019 5:36 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	020389 (AZ)		5/30/2019 5:36 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1477653889	5/30/2019 5:36 PM
Details	Last Recertification Date	Update	Recertification	11/21/2017 12:33:42 PM	8/16/2018 12:01:51 PM	8/16/2018 12:01 PM
Contacts	Primary Contact	Insert	Recertification		Roman, Michael Director of Pharmacy Little Colorado Medical Center 9282896325	11/21/2017 12:33 PM
Details	Last Recertification Date	Update	Recertification		11/21/2017 12:33:42 PM	11/21/2017 12:33 PM
Contacts	Authorizing Official	Update		Black, Ross COO 9282896345	Black, Ross COO Little Colorado Medical Center 9282896345	10/20/2017 10:12 AM
Contacts	Signed By	Update		Black, Ross COO 9282896345	Black, Ross COO Little Colorado Medical Center 9282896345	10/20/2017 10:12 AM
Contacts	Authorizing Official	Insert			Black, Ross COO 9282896345	7/13/2017 11:10 AM
Contacts	Signed By	Insert			Black, Ross COO 9282896345	7/13/2017 11:10 AM
Addresses	Main Address	Insert			200 E LEE ST LITTLE COLORADO PHYSICIANS OFFICE WINSLOW, AZ 86047-2063	6/5/2017 4:24 PM
Dates	Participating Approval Date	Update			10/17/2016 12:00:00 AM	10/17/2016 1:17 PM
Details	State	Update		Pending	Active	10/17/2016 1:17 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	10/17/2016 1:17 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_72660	CAH031311-01	10/12/2016 9:35 AM
Details	Entity Subname	Update		WINSLOW MEMORIAL HOSPITAL INC. / litlle colorado physician clinic family practice	WINSLOW MEMORIAL HOSPITAL INC. / little colorado physician clinic family practice	10/12/2016 9:35 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_72660	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: Number	Insert			020389	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: State	Insert			AZ	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: Number	Insert			1477653889	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: State	Insert			AZ	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: Number	Insert			020389	10/7/2016 12:36 PM
Medicaid Billing	Medicaid: State	Insert			AZ	10/7/2016 12:36 PM
Details	Last Recertification Date	Insert				10/7/2016 12:36 PM
Details	Grant Number	Insert				10/7/2016 12:36 PM
Details	340B ID	Insert				10/7/2016 12:36 PM
Details	Is Authorizing Official EHB Data	Insert				10/7/2016 12:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/7/2016 12:36 PM
Details	Medicare Provider Number	Insert			031311	10/7/2016 12:36 PM
Details	Entity Name	Insert			Winslow Memorial Hospital dba Little Colorado Medical Center	10/7/2016 12:36 PM
Details	Program Code	Insert			CAH	10/7/2016 12:36 PM
Details	Entity Subname	Insert			WINSLOW MEMORIAL HOSPITAL INC. / litlle colorado physician clinic family practice	10/7/2016 12:36 PM
Dates	Participating Approval Date	Insert				10/7/2016 12:36 PM
Details	State	Insert			Pending	10/7/2016 12:36 PM
Dates	Registration Date	Insert			10/7/2016 12:00:00 AM	10/7/2016 12:36 PM
Dates	Signed By Date	Insert			10/7/2016 12:00:00 AM	10/7/2016 12:36 PM
Dates	Start Date	Insert				10/7/2016 12:36 PM
Terminations	Termination Comments	Insert				10/7/2016 12:36 PM
Terminations	Termination Date	Insert				10/7/2016 12:36 PM
Terminations	Termination Effective Date	Insert				10/7/2016 12:36 PM
Terminations	Termination Reason	Insert				10/7/2016 12:36 PM