Covered Entity Details

DSH020012A FAIRBANKS MEMORIAL HOSPITAL (Active) - information as of 4/30/2025 10:57:29 PM

Main Details

Name

FAIRBANKS MEMORIAL HOSPITAL

Subdivision Name

Pain Treatment Center - Pain Treatment Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH020012A

Medicare Provider Number

020012

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/1/2020

Participating Start Date

10/1/2020

Participating Approval Date

7/21/2020

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Fairbanks Memorial Hospital
Stephen L Duprey, Sr Director of Operations
(907) 458-3669 Ext: 73669

Primary Contact

Fairbanks Memorial Hospital
Marc J Rowden, Director of Pharmacy
(907) 458-5537

Addresses

Street Address

1919 Lathrop St
221
Fairbanks, AK 99701

Billing Address

Fairbanks Memorial Hospital
1650 Cowles St
Fairbanks, AK 99701

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
AK	1655971	1720537178

Shipping Addresses

Shipping Address 1

Fairbanks Memorial Hospital Pharmacy
1650 Cowles St.
Fairbanks, AK 99701

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
DSH020012A	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	Pain Treatment Center - Pain Treatment Center	1919 Lathrop St	Fairbanks	AK	Active
DSH020012B	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FMH Radiology Satellite - Radiology	1001 Noble Street	Fairbanks	AK	Terminated
DSH020012C	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FAIRBANKS MEMORIAL HOSPITAL - Internal Medicine, Senior Care & Medication Therapy Clinic	1919 LATHROP ST	FAIRBANKS	AK	Active
DSH020012D	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FHP ORTHOPEDIC & SPINE SPECIALIST - Orthopedics	1919 LATHROP ST	FAIRBANKS	AK	Active
DSH020012E	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FHP BEHAVIOR HEALTH CLINIC - Behavioral Health & Addiction Medicine	2111 COWLES ST	FAIRBANKS	AK	Active
DSH020012F	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FAIRBANKS MEMORIAL HOSPITAL - Osteopathic Manipulation Medicine	1919 LATHROP ST	FAIRBANKS	AK	Active
DSH020012G	Child	DSH	FAIRBANKS MEMORIAL HOSPITAL	FAIRBANKS MEMORIAL HOSPITAL - Endocrinology & Diabetes Clinic	1919 LATHROP ST	FAIRBANKS	AK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/21/2023 4:29:53 PM	8/14/2024 6:58:28 PM	8/14/2024 6:58 PM
Details	Last Recertification Date	Update	Recertification	8/26/2022 2:35:57 PM	8/21/2023 4:29:53 PM	8/21/2023 4:29 PM
Contacts	Authorizing Official	Update	Change Request	Roderick, Gary W CFO Fairbanks Memorial Hospital 9074583310	Duprey, Stephen L Sr Director of Operations Fairbanks Memorial Hospital 9074583669-73669	3/15/2023 3:51 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 3:07:20 PM	8/26/2022 2:35:57 PM	8/26/2022 2:35 PM
Details	Last Recertification Date	Update	Recertification		8/17/2021 3:07:20 PM	8/17/2021 3:07 PM
Addresses	Billing Address	Insert	Change Request		Fairbanks Memorial Hospital 1650 Cowles St Fairbanks, AK 99701	10/15/2020 7:20 AM
Addresses	Shipping Address	Insert	Change Request		Fairbanks Memorial Hospital Pharmacy 1650 Cowles St. Fairbanks, AK 99701	10/15/2020 7:20 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (AZ)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (CA)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (CO)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (GA)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (IA)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (IL)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (IN)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (NE)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (NH)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (NM)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (SC)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (TN)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (UT)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (WA)		10/14/2020 7:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1720537178 (WI)		10/14/2020 7:51 PM
Details	State	Update		Approved	Active	10/1/2020 12:01 AM
Medicaid Billing	NPI: State	Update	Change Request		AK	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	9/4/2020 3:42 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1720537178	9/4/2020 3:42 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	9/4/2020 3:42 PM
Contacts	Authorizing Official	Update	Change Request	Brooks, Clint F COO Fairbanks Memorial Hospital 9074585307	Roderick, Gary W CFO Fairbanks Memorial Hospital 9074583310	8/17/2020 9:53 AM
Contacts	Signed By	Insert	New Registration		Brooks, Clint F COO Fairbanks Memorial Hospital 9074585307	7/21/2020 4:17 PM
Details	340B ID	Update	New Registration		DSH020012A	7/21/2020 4:17 PM
Details	Entity Name	Update	New Registration	FAIRBANKS MEMORIAL	FAIRBANKS MEMORIAL HOSPITAL	7/21/2020 4:17 PM
Details	Entity Subname	Update	New Registration	Pain Treatment Center	Pain Treatment Center - Pain Treatment Center	7/21/2020 4:17 PM
Dates	Participating Approval Date	Update	New Registration		7/21/2020 4:17:59 PM	7/21/2020 4:17 PM
Details	State	Update	New Registration	Pending	Approved	7/21/2020 4:17 PM
Dates	Signed By Date	Update	New Registration		7/20/2020 3:20:37 PM	7/21/2020 4:17 PM
Dates	Start Date	Update	New Registration		10/1/2020 12:00:00 AM	7/21/2020 4:17 PM
Addresses	Main Address	Insert	New Registration		1919 Lathrop St 221 Fairbanks, AK 99701	7/1/2020 5:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/1/2020 5:22 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1655971	7/1/2020 5:22 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AK	7/1/2020 5:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1720537178	7/1/2020 5:22 PM
Contacts	Primary Contact	Insert	New Registration		Rowden, Marc J Director of Pharmacy Fairbanks Memorial Hospital 9074585537	7/1/2020 5:22 PM
Contacts	Authorizing Official	Insert	New Registration		Brooks, Clint F COO Fairbanks Memorial Hospital 9074585307	7/1/2020 5:22 PM
Details	Last Recertification Date	Insert	New Registration			7/1/2020 5:22 PM
Details	Grant Number	Insert	New Registration			7/1/2020 5:22 PM
Details	340B ID	Insert	New Registration			7/1/2020 5:22 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/1/2020 5:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/1/2020 5:22 PM
Details	Medicare Provider Number	Insert	New Registration		020012	7/1/2020 5:22 PM
Details	Entity Name	Insert	New Registration		FAIRBANKS MEMORIAL	7/1/2020 5:22 PM
Details	Program Code	Insert	New Registration		DSH	7/1/2020 5:22 PM
Details	Entity Subname	Insert	New Registration		Pain Treatment Center	7/1/2020 5:22 PM
Dates	Participating Approval Date	Insert	New Registration			7/1/2020 5:22 PM
Details	State	Insert	New Registration		Pending	7/1/2020 5:22 PM
Dates	Registration Date	Insert	New Registration		7/1/2020 5:22:18 PM	7/1/2020 5:22 PM
Dates	Signed By Date	Insert	New Registration			7/1/2020 5:22 PM
Dates	Start Date	Insert	New Registration			7/1/2020 5:22 PM
Terminations	Termination Comments	Insert	New Registration			7/1/2020 5:22 PM
Terminations	Termination Date	Insert	New Registration			7/1/2020 5:22 PM
Terminations	Termination Effective Date	Insert	New Registration			7/1/2020 5:22 PM
Terminations	Termination Reason	Insert	New Registration			7/1/2020 5:22 PM