Covered Entity Details

CAH171380-03 NEOSHO MEMORIAL REGIONAL MED CTR (Active) - information as of 5/19/2025 12:45:55 AM

Main Details

Name

NEOSHO MEMORIAL REGIONAL MED CTR

Subdivision Name

NMRMC Family Medicine Clinic - NMRMC Family Medicine Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH171380-03

Medicare Provider Number

171380

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/15/2019

Participating Start Date

10/1/2019

Participating Approval Date

7/18/2019

Last Recertification Date

8/21/2024

Contacts

Authorizing Official

Neosho Memorial regional Medical Center
Wendy Brazil, COO
(620) 432-5310

Primary Contact

Neosho Memorial Regional Medical Center
Katlyn Aikins, Pharmacy Director
(620) 432-5344

Addresses

Street Address

1501 W 7th Street
Chanute, KS 66720

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
KS	30003941860002,30003941860021	1497121735

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
CAH171380-01	Child	CAH	NEOSHO MEMORIAL REGIONAL MED CTR	NMRMC WOMENS HEALTH CENTER	629 South Plummer Avenue	CHANUTE	KS	Active
CAH171380-02	Child	CAH	NEOSHO MEMORIAL REGIONAL MED CTR	NMRMC ORTHOPEDIC CLINIC	1500 W. 7th	CHANUTE	KS	Active
CAH171380-03	Child	CAH	NEOSHO MEMORIAL REGIONAL MED CTR	NMRMC Family Medicine Clinic - NMRMC Family Medicine Clinic	1501 W 7th Street	Chanute	KS	Active
CAH171380-04	Child	CAH	NEOSHO MEMORIAL REGIONAL MED CTR	NMRMC Erie Family Care Clinic - Erie Family Care Clinic	13920 HWY 59	Erie	KS	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Recertification	1501 W 7th Street Suite 2 Chanute, KS 66720	1501 W 7th Street Chanute, KS 66720	8/21/2024 6:26 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 4:07:17 PM	8/21/2024 6:26:55 AM	8/21/2024 6:26 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 4:00:08 PM	8/15/2023 4:07:17 PM	8/15/2023 4:07 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100009390C (KS)		2/8/2023 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/8/2023 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		30003941860002	2/8/2023 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	2/8/2023 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/8/2023 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		30003941860021	2/8/2023 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	2/8/2023 4:10 PM
Details	Last Recertification Date	Update	Recertification	8/31/2021 9:36:42 AM	8/25/2022 4:00:08 PM	8/25/2022 4:00 PM
Details	Last Recertification Date	Update	Recertification	8/24/2020 1:14:32 PM	8/31/2021 9:36:42 AM	8/31/2021 9:36 AM
Contacts	Authorizing Official	Update	AO Change Request	Franks, Dennis CEO Neosho Memorial Regional Medical Center 6204325313	Brazil, Wendy COO Neosho Memorial regional Medical Center 6204325310	8/24/2020 3:39 PM
Addresses	Main Address	Update	Recertification	1501 W 7th Street Chanute, KS 66720	1501 W 7th Street Suite 2 Chanute, KS 66720	8/24/2020 1:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/24/2020 1:14 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100009390C	8/24/2020 1:14 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		KS	8/24/2020 1:14 PM
Medicaid Billing	NPI: State	Update	Recertification		KS	8/24/2020 1:14 PM
Details	Last Recertification Date	Update	Recertification		8/24/2020 1:14:32 PM	8/24/2020 1:14 PM
Contacts	Primary Contact	Update	Change Request	Callarman, Frannie Staff pharmacist Neosho Memorial Regional Medical Center 6204325344	Aikins, Katlyn Pharmacy Director Neosho Memorial Regional Medical Center 6204325344	4/17/2020 3:52 PM
Contacts	Primary Contact	Update	Profile Change Request	Callarman, Frannie Director of Pharmacy Neosho Memorial Regional Medical Center 6204325344	Callarman, Frannie Staff pharmacist Neosho Memorial Regional Medical Center 6204325344	3/16/2020 11:28 AM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		Franks, Dennis CEO Neosho Memorial Regional Medical Center 6204325313	7/18/2019 9:45 AM
Details	340B ID	Update	New Registration		CAH171380-03	7/18/2019 9:45 AM
Details	Entity Subname	Update	New Registration	NMRMC Family Medicine Clinic	NMRMC Family Medicine Clinic - NMRMC Family Medicine Clinic	7/18/2019 9:45 AM
Dates	Participating Approval Date	Update	New Registration		7/18/2019 9:45:20 AM	7/18/2019 9:45 AM
Details	State	Update	New Registration	Pending	Approved	7/18/2019 9:45 AM
Dates	Signed By Date	Update	New Registration		7/15/2019 4:58:35 PM	7/18/2019 9:45 AM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	7/18/2019 9:45 AM
Addresses	Main Address	Insert	New Registration		1501 W 7th Street Chanute, KS 66720	7/15/2019 4:49 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1497121735	7/15/2019 4:49 PM
Contacts	Primary Contact	Insert	New Registration		Callarman, Frannie Director of Pharmacy Neosho Memorial Regional Medical Center 6204325344	7/15/2019 4:49 PM
Contacts	Authorizing Official	Insert	New Registration		Franks, Dennis CEO Neosho Memorial Regional Medical Center 6204325313	7/15/2019 4:49 PM
Details	Last Recertification Date	Insert	New Registration			7/15/2019 4:49 PM
Details	Grant Number	Insert	New Registration			7/15/2019 4:49 PM
Details	340B ID	Insert	New Registration			7/15/2019 4:49 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/15/2019 4:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/15/2019 4:49 PM
Details	Medicare Provider Number	Insert	New Registration		171380	7/15/2019 4:49 PM
Details	Entity Name	Insert	New Registration		NEOSHO MEMORIAL REGIONAL MED CTR	7/15/2019 4:49 PM
Details	Program Code	Insert	New Registration		CAH	7/15/2019 4:49 PM
Details	Entity Subname	Insert	New Registration		NMRMC Family Medicine Clinic	7/15/2019 4:49 PM
Dates	Participating Approval Date	Insert	New Registration			7/15/2019 4:49 PM
Details	State	Insert	New Registration		Pending	7/15/2019 4:49 PM
Dates	Registration Date	Insert	New Registration		7/15/2019 4:49:23 PM	7/15/2019 4:49 PM
Dates	Signed By Date	Insert	New Registration			7/15/2019 4:49 PM
Dates	Start Date	Insert	New Registration			7/15/2019 4:49 PM
Terminations	Termination Comments	Insert	New Registration			7/15/2019 4:49 PM
Terminations	Termination Date	Insert	New Registration			7/15/2019 4:49 PM
Terminations	Termination Effective Date	Insert	New Registration			7/15/2019 4:49 PM
Terminations	Termination Reason	Insert	New Registration			7/15/2019 4:49 PM