Covered Entity Details

SCH260064-06 SSM HEALTH-ST.MARY'S AUDRAIN (Terminated) - information as of 5/13/2025 1:33:56 AM

Main Details

Name

SSM HEALTH-ST.MARY'S AUDRAIN

Subdivision Name

Pediatrics Clinic - Pediatrics

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH260064-06

Medicare Provider Number

260064

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/12/2018

Participating Start Date

7/1/2018

Participating Approval Date

6/12/2018

Last Recertification Date

8/30/2019

Termination Date
Termination Reason

10/1/2019
Site closure

Contacts

Authorizing Official

SSM Health
Becky Miller, Vice President-Hospital Operations
(573) 681-3136

Primary Contact

SSM Health
Jeffrey Peine, Finance Director
(314) 989-3532

Addresses

Street Address

3626 S Clark Street Suite A
Mexico, MO 65265

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
MO	010328102
		1952390122

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
SCH260064-01	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Urgent Care - Urgent Care	3626 S Clark Street Suite C	Mexico	MO	Terminated
SCH260064-02	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Family Medicine-Fulton - Family Medicine	350 Country Meadows Lane	Fulton	MO	Terminated
SCH260064-03	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Family Medicine-Vandalia - Family Medicine	204 W Washington	Vandalia	MO	Terminated
SCH260064-04	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Family Medicine-Medical Park - Family Medicine	3626 S Clark Street	Mexico	MO	Terminated
SCH260064-05	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Family Medicine-Perry - Family Medicine	1223 Main Street	Perry	MO	Terminated
SCH260064-06	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Pediatrics Clinic - Pediatrics	3626 S Clark Street Suite A	Mexico	MO	Terminated
SCH260064-07	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Family Medicine-Montgomery - Family Medicine	240 N Pickering	Montgomery City	MO	Terminated
SCH260064-08	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Family Medicine-Wellsville - Family Medicine	111 W Bates	Wellsville	MO	Terminated
SCH260064-09	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Internal Medicine-Mexico - Internal Medicine	600 Medical Park Drive	Mexico	MO	Terminated
SCH260064-10	Child	SCH	SSM HEALTH-ST.MARY'S AUDRAIN	Family Medicine-Auxvasse - Family Medicine	201 S Main Street	Auxvasse	MO	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Jacobs, Donna President, SSM Audrain Health Center SSM Health 5735828103	Miller, Becky Vice President-Hospital Operations SSM Health 5736813136	5/6/2020 7:54 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/1/2019 12:00:00 AM	9/10/2019 7:10 AM
Details	State	Update	Termination Request	Active	To Be Terminated	9/10/2019 7:10 AM
Terminations	Termination Comments	Update	Termination Request		Clinic closed.	9/10/2019 7:10 AM
Terminations	Termination Date	Update	Termination Request		10/1/2019 12:00:00 AM	9/10/2019 7:10 AM
Terminations	Termination Effective Date	Update	Termination Request		10/1/2019 12:00:00 AM	9/10/2019 7:10 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	9/10/2019 7:10 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 12:14:57 PM	8/30/2019 5:57:47 PM	8/30/2019 5:57 PM
Details	Last Recertification Date	Update	Recertification		8/16/2018 12:14:57 PM	8/16/2018 12:14 PM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Details	Entity Name	Update	Change Request	AUDRAIN MEDICAL CENTER	SSM HEALTH-ST.MARY'S AUDRAIN	6/14/2018 4:28 PM
Contacts	Signed By	Insert	New Registration		Jacobs, Donna President, SSM Audrain Health Center SSM Health 5735828103	6/12/2018 2:00 PM
Details	340B ID	Update	New Registration		SCH260064-06	6/12/2018 2:00 PM
Details	Entity Subname	Update	New Registration	Pediatrics Clinic	Pediatrics Clinic - Pediatrics	6/12/2018 2:00 PM
Dates	Participating Approval Date	Update	New Registration		6/12/2018 2:00:47 PM	6/12/2018 2:00 PM
Details	State	Update	New Registration	Pending	Approved	6/12/2018 2:00 PM
Dates	Signed By Date	Update	New Registration		4/12/2018 3:31:31 PM	6/12/2018 2:00 PM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	6/12/2018 2:00 PM
Contacts	Primary Contact	Update	Profile Change Request	Peine, Jeffrey Sr. Financial Analyst 340B SSM Health 3149893532	Peine, Jeffrey Finance Director SSM Health 3149893532	4/12/2018 5:13 PM
Addresses	Main Address	Insert	New Registration		3626 S Clark Street Suite A Mexico, MO 65265	4/12/2018 11:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2018 11:48 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010328102	4/12/2018 11:48 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	4/12/2018 11:48 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1952390122	4/12/2018 11:48 AM
Contacts	Primary Contact	Insert	New Registration		Peine, Jeffrey Sr. Financial Analyst 340B SSM Health 3149893532	4/12/2018 11:48 AM
Contacts	Authorizing Official	Insert	New Registration		Jacobs, Donna President, SSM Audrain Health Center SSM Health 5735828103	4/12/2018 11:48 AM
Details	Last Recertification Date	Insert	New Registration			4/12/2018 11:48 AM
Details	Grant Number	Insert	New Registration			4/12/2018 11:48 AM
Details	340B ID	Insert	New Registration			4/12/2018 11:48 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/12/2018 11:48 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/12/2018 11:48 AM
Details	Medicare Provider Number	Insert	New Registration		260064	4/12/2018 11:48 AM
Details	Entity Name	Insert	New Registration		AUDRAIN MEDICAL CENTER	4/12/2018 11:48 AM
Details	Program Code	Insert	New Registration		SCH	4/12/2018 11:48 AM
Details	Entity Subname	Insert	New Registration		Pediatrics Clinic	4/12/2018 11:48 AM
Dates	Participating Approval Date	Insert	New Registration			4/12/2018 11:48 AM
Details	State	Insert	New Registration		Pending	4/12/2018 11:48 AM
Dates	Registration Date	Insert	New Registration		4/12/2018 11:48:48 AM	4/12/2018 11:48 AM
Dates	Signed By Date	Insert	New Registration			4/12/2018 11:48 AM
Dates	Start Date	Insert	New Registration			4/12/2018 11:48 AM
Terminations	Termination Comments	Insert	New Registration			4/12/2018 11:48 AM
Terminations	Termination Date	Insert	New Registration			4/12/2018 11:48 AM
Terminations	Termination Effective Date	Insert	New Registration			4/12/2018 11:48 AM
Terminations	Termination Reason	Insert	New Registration			4/12/2018 11:48 AM