Covered Entity Details

DSH160104 TRINITY BETTENDORF (Active) - information as of 4/25/2025 9:21:37 PM

Main Details

Name

TRINITY BETTENDORF

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH160104

Medicare Provider Number

160104

Additional Details

Current Program Status

Active

Registration Date

1/5/2017

Participating Start Date

4/1/2017

Participating Approval Date

2/14/2017

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

UnityPoint-Trinity
Dave Dellitt, Chief Financial Officer
(309) 779-2218

Primary Contact

UnityPoint - Trinity
Jaime Graves, 340B Pharmacy Coordinator
(309) 779-5030

Addresses

Street Address

4500 UTICA RIDGE ROAD
BETTENDORF, IA 52722

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
IA	0601286	1124110820
IL	362739299008	1124110820
WI		1124110820

Shipping Addresses

Shipping Address 1

Trinity Medical Center
2701 17th Street
Rock Island, IL 61201

Shipping Address 2

Trinity Bettendorf
4500 Utica Ridge Road
Bettendorf, IA 52722-0000

Shipping Address 3

Trinity Medical Center DBA: Trinity Moline
500 John Deere Road
Moline, IL 61265

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	01/11/2021	04/01/2021	01/01/2025	01/09/2025
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	01/11/2021	04/01/2021	10/13/2022	10/13/2022
Contract Detail	UNITYPOINT AT HOME	11333 AURORA AVE		URBANDALE	IA	50322	01/11/2021	04/01/2021		02/16/2024
Contract Detail	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	01/10/2023	04/01/2023		04/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 11709	1805 BRADY ST	DAVENPORT	IA	52803	10/12/2017	01/01/2018	04/18/2024	05/07/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05239	1660 W LOCUST ST	DAVENPORT	IA	52804	10/12/2017	01/01/2018		10/12/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06553	830 MIDDLE ROAD	BETTENDORF	IA	52722-4101	07/12/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05512	3425 MIDDLE ROAD	BETTENDORF	IA	52722	07/12/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06186	4011 E 53RD ST	DAVENPORT	IA	52807	07/12/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04041	1525 E KIMBERLY RD	DAVENPORT	IA	52807	10/07/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03595	1720 W. KIMBERLY RD.	DAVENPORT	IA	52806	10/07/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09515	1301 AVENUE OF THE CITIES	EAST MOLINE	IL	61244	01/10/2023	04/01/2023		04/01/2023
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/11/2021	04/01/2021	01/01/2025	01/09/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/11/2021	04/01/2021	01/01/2025	01/09/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/11/2021	04/01/2021	10/01/2021	10/19/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/11/2021	04/01/2021	01/01/2025	01/09/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH160104A	Child	DSH	TRINITY BETTENDORF	UnityPoint Health Trinity Bettendorf Multi Specialty Clinic - Multi Specialty	4480 Utica Ridge Road	Bettendorf	IA	Active
DSH160104B	Child	DSH	TRINITY BETTENDORF	Trinity Bettendorf - Pain Management - Clinic	4480 Utica Ridge Road	Bettendorf	IA	Active
DSH160104C	Child	DSH	TRINITY BETTENDORF	Trinity Bettendorf - Wound Care - Clinic	4480 Utica Ridge Road	Bettendorf	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 2:52:56 PM	8/14/2024 8:22:37 AM	8/14/2024 8:22 AM
Contacts	Authorizing Official	Update	Profile Change Request	Dellitt, Dave Director of Finance UnityPoint-Trinity 3097792954	Dellitt, Dave Chief Financial Officer UnityPoint-Trinity 3097792218	2/16/2024 6:15 AM
Contacts	Signed By	Update	Profile Change Request	Dellitt, Dave Director of Finance UnityPoint-Trinity 3097792954	Dellitt, Dave Chief Financial Officer UnityPoint-Trinity 3097792218	2/16/2024 6:15 AM
Addresses	Shipping Address	Delete	Change Request	Safecor Health 4060 Business Park Drive, Suite B Columbus, OH 43204		1/12/2024 7:34 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 1:29:59 PM	8/29/2023 2:52:56 PM	8/29/2023 2:52 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1124110820 (MN)		6/13/2023 12:13 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1124110820 (MO)		6/13/2023 12:13 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1124110820 (NE)		6/13/2023 12:13 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 3:50:05 PM	9/8/2022 1:29:59 PM	9/8/2022 1:29 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 7:13:08 PM	9/7/2021 3:50:05 PM	9/7/2021 3:50 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1124110820	9/10/2020 7:13 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/10/2020 7:13 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1124110820	9/10/2020 7:13 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/10/2020 7:13 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1124110820	9/10/2020 7:13 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/10/2020 7:13 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1124110820	9/10/2020 7:13 PM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/10/2020 7:13 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1124110820	9/10/2020 7:13 PM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/10/2020 7:13 PM
Medicaid Billing	NPI: State	Update	Recertification		IA	9/10/2020 7:13 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 9:11:41 AM	9/10/2020 7:13:08 PM	9/10/2020 7:13 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 11:34:08 AM	9/5/2019 9:11:41 AM	9/5/2019 9:11 AM
Details	Last Recertification Date	Update	Recertification	11/29/2017 3:18:01 PM	8/22/2018 11:34:08 AM	8/22/2018 11:34 AM
Details	Last Recertification Date	Update	Recertification		11/29/2017 3:18:01 PM	11/29/2017 3:18 PM
Contacts	Primary Contact	Update	Profile Change Request	Graves, Jaime 340B Pharmacy Coordinator UnityPoint Health - Trinity 3097795030	Graves, Jaime 340B Pharmacy Coordinator UnityPoint - Trinity 3097795030	10/24/2017 12:35 PM
Contacts	Primary Contact	Update	Profile Change Request	Graves, Jaime 340B Pharmacy Coordinator Trinity Muscatine 3097795030	Graves, Jaime 340B Pharmacy Coordinator UnityPoint Health - Trinity 3097795030	10/18/2017 8:56 AM
Contacts	Primary Contact	Insert	Change Request		Graves, Jaime 340B Pharmacy Coordinator Trinity Muscatine 3097795030	10/12/2017 6:28 PM
Contacts	Authorizing Official	Update		Dellitt, Dave Director of Finance 3097792954	Dellitt, Dave Director of Finance UnityPoint-Trinity 3097792954	10/3/2017 10:27 AM
Contacts	Signed By	Update		Dellitt, Dave Director of Finance 3097792954	Dellitt, Dave Director of Finance UnityPoint-Trinity 3097792954	10/3/2017 10:27 AM
Contacts	Authorizing Official	Insert			Dellitt, Dave Director of Finance 3097792954	6/19/2017 2:26 PM
Contacts	Signed By	Insert			Dellitt, Dave Director of Finance 3097792954	6/19/2017 2:26 PM
Addresses	Main Address	Insert			4500 UTICA RIDGE ROAD BETTENDORF, IA 52722	5/23/2017 10:03 AM
Addresses	Shipping Address	Insert			Trinity Medical Center 2701 17th Street Rock Island, IL 61201	5/23/2017 10:03 AM
Addresses	Shipping Address	Insert			Trinity Medical Center DBA: Trinity Moline 500 John Deere Road Moline, IL 61265	5/23/2017 10:03 AM
Addresses	Shipping Address	Insert			Safecor Health 4060 Business Park Drive, Suite B Columbus, OH 43204	5/23/2017 10:03 AM
Addresses	Shipping Address	Insert			Trinity Bettendorf 4500 Utica Ridge Road Bettendorf, IA 52722-0000	5/23/2017 10:03 AM
Dates	Participating Approval Date	Update			2/14/2017 12:00:00 AM	2/14/2017 5:21 PM
Details	State	Update		Pending	Active	2/14/2017 5:21 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	2/14/2017 5:21 PM
Details	340B ID	Update		ONLINE_REG_73803	DSH160104	1/5/2017 1:24 PM
Details	340B ID	Update			ONLINE_REG_73803	1/5/2017 9:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/5/2017 9:47 AM
Medicaid Billing	Medicaid: Number	Insert			0601286	1/5/2017 9:47 AM
Medicaid Billing	Medicaid: State	Insert			IA	1/5/2017 9:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/5/2017 9:47 AM
Medicaid Billing	Medicaid: Number	Insert			362739299008	1/5/2017 9:47 AM
Medicaid Billing	Medicaid: State	Insert			IL	1/5/2017 9:47 AM
Medicaid Billing	NPI: Number	Insert			1124110820	1/5/2017 9:47 AM
Details	Last Recertification Date	Insert				1/5/2017 9:47 AM
Details	Grant Number	Insert				1/5/2017 9:47 AM
Details	340B ID	Insert				1/5/2017 9:47 AM
Details	Is Authorizing Official EHB Data	Insert				1/5/2017 9:47 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/5/2017 9:47 AM
Details	Medicare Provider Number	Insert			160104	1/5/2017 9:47 AM
Details	Entity Name	Insert			TRINITY BETTENDORF	1/5/2017 9:47 AM
Details	Program Code	Insert			DSH	1/5/2017 9:47 AM
Details	Entity Subname	Insert				1/5/2017 9:47 AM
Dates	Participating Approval Date	Insert				1/5/2017 9:47 AM
Details	State	Insert			Pending	1/5/2017 9:47 AM
Dates	Registration Date	Insert			1/5/2017 12:00:00 AM	1/5/2017 9:47 AM
Dates	Signed By Date	Insert			1/5/2017 12:00:00 AM	1/5/2017 9:47 AM
Dates	Start Date	Insert				1/5/2017 9:47 AM
Terminations	Termination Comments	Insert				1/5/2017 9:47 AM
Terminations	Termination Date	Insert				1/5/2017 9:47 AM
Terminations	Termination Effective Date	Insert				1/5/2017 9:47 AM
Terminations	Termination Reason	Insert				1/5/2017 9:47 AM