Covered Entity Details

CAH171344-01 WILSON MEDICAL CENTER (Active) - information as of 5/1/2025 11:53:32 PM

Main Details

Name

WILSON MEDICAL CENTER

Subdivision Name

Wilson County Hospital dba Independence Family Medicine

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH171344-01

Medicare Provider Number

171344

Outpatient Facility Provider Number

178582

Additional Details

Current Program Status

Active

Registration Date

1/17/2017

Participating Start Date

4/1/2017

Participating Approval Date

1/30/2017

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

Wilson County Hospital
Lori Smith, CFO
(620) 325-8388

Primary Contact

WILSON COUNTY HOSPITAL
Travis A Coffield, Pharmacy Director
(620) 325-8334

Addresses

Street Address

1415 N Pennsylvania Ave
Independence, KS 67301-2222

Billing Address

Wilson Medical Center
2600 Ottawa RD
Neodesha, KS 66757

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?
No

Shipping Addresses

Shipping Address 1

Wilson Medical Center
2600 Ottawa Road
Neodesha, KS 66757

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
CAH171344-01	Child	CAH	WILSON MEDICAL CENTER	Wilson County Hospital dba Independence Family Medicine	1415 N Pennsylvania Ave	Independence	KS	Active
CAH171344-02	Child	CAH	WILSON MEDICAL CENTER	Wilson County Hospital DBA Cherryvale Family Medicine	203 W Main St	Cherryvale	KS	ToBeTerminated
CAH171344-03	Child	CAH	WILSON MEDICAL CENTER	WILSON COUNTY HOSPITAL DBA NEODESHA FAMILY MEDICINE	2600 Ottawa Rd	NEODESHA	KS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/14/2023 9:26:20 AM	8/15/2024 10:09:53 AM	8/15/2024 10:09 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 1:49:34 PM	8/14/2023 9:26:20 AM	8/14/2023 9:26 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 5:44:06 PM	8/25/2022 1:49:34 PM	8/25/2022 1:49 PM
Addresses	Billing Address	Update	Recertification	Wilson Medical Center PO Box 360 Neodesha, KS 66757	Wilson Medical Center 2600 Ottawa RD Neodesha, KS 66757	8/24/2021 5:44 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 3:43:54 PM	8/24/2021 5:44:06 PM	8/24/2021 5:44 PM
Contacts	Authorizing Official	Update	Change Request	Gutschenritter, John CFO WILSON COUNTY HOSPITAL 6203258388	Smith, Lori CFO Wilson County Hospital 6203258388	8/23/2021 10:12 AM
Details	Last Recertification Date	Update	Recertification	8/27/2019 4:13:17 PM	9/8/2020 3:43:54 PM	9/8/2020 3:43 PM
Addresses	Main Address	Update	Recertification	1415 North Pennsylvania Avenue Independence, KS 67301	1415 N Pennsylvania Ave Independence, KS 67301-2222	8/27/2019 4:13 PM
Details	Last Recertification Date	Update	Recertification	8/27/2018 11:21:25 AM	8/27/2019 4:13:17 PM	8/27/2019 4:13 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 11:46:37 AM	8/27/2018 11:21:25 AM	8/27/2018 11:21 AM
Details	Last Recertification Date	Update	Recertification		11/7/2017 11:46:37 AM	11/7/2017 11:46 AM
Contacts	Primary Contact	Update	Recertification	Coffield, Travis Pharmacy Director WILSON COUNTY HOSPITAL 6203258334	Coffield, Travis A Pharmacy Director WILSON COUNTY HOSPITAL 6203258334	11/7/2017 11:43 AM
Contacts	Primary Contact	Update		Coffield, Travis Pharmacy Director 6203258334	Coffield, Travis Pharmacy Director WILSON COUNTY HOSPITAL 6203258334	10/23/2017 2:51 PM
Contacts	Authorizing Official	Update		Gutschenritter, John CFO 6203258388	Gutschenritter, John CFO WILSON COUNTY HOSPITAL 6203258388	10/23/2017 10:21 AM
Contacts	Signed By	Update		Gutschenritter, John CFO 6203258388	Gutschenritter, John CFO WILSON COUNTY HOSPITAL 6203258388	10/23/2017 10:21 AM
Contacts	Authorizing Official	Insert			Gutschenritter, John CFO 6203258388	8/14/2017 12:28 PM
Contacts	Signed By	Insert			Gutschenritter, John CFO 6203258388	8/14/2017 12:28 PM
Addresses	Main Address	Insert			1415 North Pennsylvania Avenue Independence, KS 67301	7/21/2017 12:42 PM
Addresses	Billing Address	Insert			Wilson Medical Center PO Box 360 Neodesha, KS 66757	7/21/2017 12:42 PM
Addresses	Shipping Address	Insert			Wilson Medical Center 2600 Ottawa Road Neodesha, KS 66757	7/21/2017 12:42 PM
Contacts	Primary Contact	Insert			Coffield, Travis Pharmacy Director 6203258334	7/21/2017 12:42 PM
Dates	Participating Approval Date	Update			1/30/2017 12:00:00 AM	1/30/2017 4:27 PM
Details	State	Update		Pending	Active	1/30/2017 4:27 PM
Dates	Start Date	Update			4/1/2017 12:00:00 AM	1/30/2017 4:27 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_75182	CAH171344-01	1/27/2017 3:30 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_75182	1/17/2017 10:08 AM
Details	Last Recertification Date	Insert				1/17/2017 10:08 AM
Details	Grant Number	Insert				1/17/2017 10:08 AM
Details	340B ID	Insert				1/17/2017 10:08 AM
Details	Is Authorizing Official EHB Data	Insert				1/17/2017 10:08 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/17/2017 10:08 AM
Details	Medicare Provider Number	Insert			171344	1/17/2017 10:08 AM
Details	Entity Name	Insert			WILSON MEDICAL CENTER	1/17/2017 10:08 AM
Details	Program Code	Insert			CAH	1/17/2017 10:08 AM
Details	Entity Subname	Insert			Wilson County Hospital dba Independence Family Medicine	1/17/2017 10:08 AM
Dates	Participating Approval Date	Insert				1/17/2017 10:08 AM
Details	State	Insert			Pending	1/17/2017 10:08 AM
Dates	Registration Date	Insert			1/17/2017 12:00:00 AM	1/17/2017 10:08 AM
Dates	Signed By Date	Insert			1/17/2017 12:00:00 AM	1/17/2017 10:08 AM
Dates	Start Date	Insert				1/17/2017 10:08 AM
Terminations	Termination Comments	Insert				1/17/2017 10:08 AM
Terminations	Termination Date	Insert				1/17/2017 10:08 AM
Terminations	Termination Effective Date	Insert				1/17/2017 10:08 AM
Terminations	Termination Reason	Insert				1/17/2017 10:08 AM