Covered Entity Details

DSH160110D Allen Memorial Hospital Corporation (Active) - information as of 5/3/2025 11:29:03 PM

Main Details

Name

Allen Memorial Hospital Corporation

Subdivision Name

ALLEN HOSPITAL COMMUNITY CANCER CENTER

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH160110D

Medicare Provider Number

160110

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/10/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/20/2017

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Allen Memorial Hospital Corporation
Jennifer A Friedly, President
(319) 235-3997

Primary Contact

Allen Memorial Hospital Corporation
Natalie Arlene Hunter, VP Operations
(319) 235-3660

Addresses

Street Address

3530 W 4TH ST.
WATERLOO, IA 50701-4503

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	0601104	1336231091
IL		1336231091
WI		1336231091

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
DSH160110A	Child	DSH	Allen Memorial Hospital Corporation	Allen Hospital Pain Center	3630 West Fourth Street	Waterloo	IA	Active
DSH160110B	Child	DSH	Allen Memorial Hospital Corporation	Allen Hospital Ambulatory Surgery Center	1731 West Ridgeway	Waterloo	IA	Terminated
DSH160110C	Child	DSH	Allen Memorial Hospital Corporation	Allen Hospital Digestive Health Center	125 East Tower Park	Waterloo	IA	Terminated
DSH160110D	Child	DSH	Allen Memorial Hospital Corporation	ALLEN HOSPITAL COMMUNITY CANCER CENTER	3530 W 4TH ST.	WATERLOO	IA	Active
DSH160110E	Child	DSH	Allen Memorial Hospital Corporation	UNITY POINT HEALTH WATERLOO CENTER FOR UROLOGY	1717 W RIDGEWAY AVE	WATERLOO	IA	Terminated
DSH160110F	Child	DSH	Allen Memorial Hospital Corporation	Allen Memorial Hospital Community Cancer Center - Oncology Clinic	1753 W Ridgeway	Waterloo	IA	Terminated
DSH160110G	Child	DSH	Allen Memorial Hospital Corporation	Allen Memorial Hospital Infusion Center - Infusion Services	1731 W Ridgeway	Waterloo	IA	Terminated
DSH160110H	Child	DSH	Allen Memorial Hospital Corporation	Medication Management - UMP - Medication Management	1731 W Ridgeway	Waterloo	IA	Active
DSH160110J	Child	DSH	Allen Memorial Hospital Corporation	UnityPoint Health- Allen Hospital Cardiovascular Center - Cardiology	419 East Donald Street	Waterloo	IA	Active
DSH160110K	Child	DSH	Allen Memorial Hospital Corporation	UnityPoint Health- Allen Hospital Medication Management Clinic Cardiology - Medication Management	419 East Donald Street	Waterloo	IA	Active
DSH160110L	Child	DSH	Allen Memorial Hospital Corporation	Allen Memorial Hospital Infusion Center Department - Infusion	164 West Dale St	Waterloo	IA	Active
DSH160110M	Child	DSH	Allen Memorial Hospital Corporation	UnityPoint Health Allen Hospital Cardiovascular Center Ridgeway - Cardiovascular Clinic	2413 West Ridgeway Ave	Waterloo	IA	Active
DSH160110N	Child	DSH	Allen Memorial Hospital Corporation	UnityPoint Health Allen Hospital Pulmonology - Pulmonology	152 West Dale St	Waterloo	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Change Request		1336231091	10/8/2024 7:35 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/8/2024 7:35 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1336231091	10/8/2024 7:35 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	10/8/2024 7:35 PM
Details	Last Recertification Date	Update	Recertification	8/16/2023 12:05:51 PM	8/13/2024 9:57:39 AM	8/13/2024 9:57 AM
Contacts	Primary Contact	Update	Profile Change Request	Hunter, Natalie Arlene Director Pharmacy Allen Memorial Hospital Corporation 3192353660	Hunter, Natalie Arlene VP Operations Allen Memorial Hospital Corporation 3192353660	7/11/2024 3:41 PM
Contacts	Authorizing Official	Update	Profile Change Request	Friedly, Jennifer A Vice President/Chief Operating Officer Allen Memorial Hospital Corporation 3192353997	Friedly, Jennifer A President Allen Memorial Hospital Corporation 3192353997	10/10/2023 8:52 AM
Details	Last Recertification Date	Update	Recertification	9/12/2022 8:00:58 AM	8/16/2023 12:05:51 PM	8/16/2023 12:05 PM
Contacts	Authorizing Official	Update	Change Request	Delagardelle, Pamela K. President/CEO Allen Memorial Hospital 3192353606	Friedly, Jennifer A Vice President/Chief Operating Officer Allen Memorial Hospital Corporation 3192353997	8/11/2023 7:17 AM
Details	Last Recertification Date	Update	Recertification	9/3/2021 11:39:11 AM	9/12/2022 8:00:58 AM	9/12/2022 8:00 AM
Contacts	Primary Contact	Update		Hunter, Natalie Director Pharmacy Allen Memorial Hospital Corporation 3192353660	Hunter, Natalie Arlene Director Pharmacy Allen Memorial Hospital Corporation 3192353660	4/18/2022 1:13 PM
Contacts	Primary Contact	Update	Change Request	Phillips, Dave B Director Compliance Allen Memorial Hospital Corporation 3193697121	Hunter, Natalie Director Pharmacy Allen Memorial Hospital Corporation 3192353660	3/2/2022 6:49 AM
Details	Last Recertification Date	Update	Recertification	9/3/2020 4:03:23 PM	9/3/2021 11:39:11 AM	9/3/2021 11:39 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1336231091	9/3/2020 4:03 PM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/3/2020 4:03 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1336231091 ( )		9/3/2020 4:03 PM
Details	Last Recertification Date	Update	Recertification	9/11/2019 5:34:34 PM	9/3/2020 4:03:23 PM	9/3/2020 4:03 PM
Details	Last Recertification Date	Update	Recertification	9/7/2018 10:16:22 AM	9/11/2019 5:34:34 PM	9/11/2019 5:34 PM
Contacts	Authorizing Official	Update	AO Change Request	Flanagan, Craig CFO and Strategy Officer UnityPoint Health 3192353918	Delagardelle, Pamela K. President/CEO Allen Memorial Hospital 3192353606	10/2/2018 3:02 PM
Details	Entity Name	Update	Recertification	ALLEN MEMORIAL HOSPITAL	Allen Memorial Hospital Corporation	9/7/2018 11:33 AM
Contacts	Primary Contact	Update	Recertification	STAFFORD, TORI K EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE Allen Memorial Hospital Corporation 3192353913	Phillips, Dave B Director Compliance Allen Memorial Hospital Corporation 3193697121	9/7/2018 10:16 AM
Details	Last Recertification Date	Update	Recertification	11/11/2017 9:22:17 AM	9/7/2018 10:16:22 AM	9/7/2018 10:16 AM
Details	Last Recertification Date	Update	Recertification		11/11/2017 9:22:17 AM	11/11/2017 9:22 AM
Contacts	Primary Contact	Update	Recertification	STAFFORD, TORI EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE Allen Memorial Hospital Corporation 3192353913	STAFFORD, TORI K EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE Allen Memorial Hospital Corporation 3192353913	11/3/2017 5:06 AM
Contacts	Authorizing Official	Update		Flanagan, Craig CFO and Strategy Officer 3192353918	Flanagan, Craig CFO and Strategy Officer UnityPoint Health 3192353918	10/29/2017 10:33 AM
Contacts	Primary Contact	Update		STAFFORD, TORI EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE 3192353913	STAFFORD, TORI EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE Allen Memorial Hospital Corporation 3192353913	10/9/2017 12:04 AM
Addresses	Main Address	Insert			3530 W 4TH ST. WATERLOO, IA 50701-4503	6/15/2017 2:25 PM
Contacts	Primary Contact	Insert			STAFFORD, TORI EXECUTIVE DIRECTOR OF MED AFFAIRS AND COMPLIANCE 3192353913	6/15/2017 2:25 PM
Contacts	Authorizing Official	Insert			Flanagan, Craig CFO and Strategy Officer 3192353918	6/15/2017 2:25 PM
Contacts	Signed By	Insert			Carpenter, Dan Regional Vice President/CFO 3192353918	6/15/2017 2:25 PM
Dates	Participating Approval Date	Update			4/20/2017 12:00:00 AM	4/20/2017 5:03 PM
Details	State	Update		Pending	Active	4/20/2017 5:03 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/20/2017 5:03 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_76358	DSH160110D	4/11/2017 7:24 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_76358	4/10/2017 3:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/10/2017 3:37 PM
Medicaid Billing	Medicaid: Number	Insert			0601104	4/10/2017 3:37 PM
Medicaid Billing	Medicaid: State	Insert			IA	4/10/2017 3:37 PM
Medicaid Billing	NPI: Number	Insert			1336231091	4/10/2017 3:37 PM
Details	Last Recertification Date	Insert				4/10/2017 3:37 PM
Details	Grant Number	Insert				4/10/2017 3:37 PM
Details	340B ID	Insert				4/10/2017 3:37 PM
Details	Is Authorizing Official EHB Data	Insert				4/10/2017 3:37 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/10/2017 3:37 PM
Details	Medicare Provider Number	Insert			160110	4/10/2017 3:37 PM
Details	Entity Name	Insert			ALLEN MEMORIAL HOSPITAL	4/10/2017 3:37 PM
Details	Program Code	Insert			DSH	4/10/2017 3:37 PM
Details	Entity Subname	Insert			ALLEN HOSPITAL COMMUNITY CANCER CENTER	4/10/2017 3:37 PM
Dates	Participating Approval Date	Insert				4/10/2017 3:37 PM
Details	State	Insert			Pending	4/10/2017 3:37 PM
Dates	Registration Date	Insert			4/10/2017 12:00:00 AM	4/10/2017 3:37 PM
Dates	Signed By Date	Insert			4/10/2017 12:00:00 AM	4/10/2017 3:37 PM
Dates	Start Date	Insert				4/10/2017 3:37 PM
Terminations	Termination Comments	Insert				4/10/2017 3:37 PM
Terminations	Termination Date	Insert				4/10/2017 3:37 PM
Terminations	Termination Effective Date	Insert				4/10/2017 3:37 PM
Terminations	Termination Reason	Insert				4/10/2017 3:37 PM