Covered Entity Details

SCH260017-02 PHELPS COUNTY REGIONAL MEDICAL CNTR (Terminated) - information as of 4/25/2025 9:21:11 PM

Main Details

Name

PHELPS COUNTY REGIONAL MEDICAL CNTR

Subdivision Name

Phelps Health Ambulatory Surgery Center - Ambulatory Surgery

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH260017-02

Medicare Provider Number

260017

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

9/24/2020

Participating Start Date

9/30/2020

Participating Approval Date

9/30/2020

Last Recertification Date

Termination Date
Termination Reason

3/2/2021
Other

Contacts

Authorizing Official

Phelps County Regional Medical Center
Jana Cook, Chief Financial Officer
(573) 458-7916

Primary Contact

Phelps County Regional Medical Center
KREIG Leland MOORE, DIRECTOR OF PHARMACY
(573) 458-7892

Addresses

Street Address

1050 West 10th Street
2nd Floor Medical Office Building
Rolla, MO 65401

Billing Address

Phelps Health
1000 West 10th Street
Rolla, MO 65401

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	010419109	1891766051

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
SCH260017-01	Child	SCH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health Onclolgy Services - Oncology	1060 West 10th Street	Rolla	MO	Terminated
SCH260017-02	Child	SCH	PHELPS COUNTY REGIONAL MEDICAL CNTR	Phelps Health Ambulatory Surgery Center - Ambulatory Surgery	1050 West 10th Street	Rolla	MO	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Dates	Last Date That 340B Drugs Purchased	Update	OPA Edit Termination Info	4/1/2021 12:00:00 AM	3/2/2021 12:00:00 AM	3/2/2021 1:36 PM
Details	State	Update	OPA Edit Termination Info	To Be Terminated	Terminated	3/2/2021 1:36 PM
Terminations	Termination Comments	Update	OPA Edit Termination Info		DUE to COVID 19-CE going from SCH to DSH	3/2/2021 1:36 PM
Terminations	Termination Date	Update	OPA Edit Termination Info	4/1/2021 12:00:00 AM	3/2/2021 12:00:00 AM	3/2/2021 1:36 PM
Terminations	Termination Effective Date	Update	OPA Edit Termination Info	4/1/2021 12:00:00 AM	3/2/2021 12:00:00 AM	3/2/2021 1:36 PM
Terminations	Termination Reason	Update	OPA Edit Termination Info	Change of covered entity type	Other	3/2/2021 1:36 PM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2021 12:00:00 AM	3/2/2021 1:30 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	3/2/2021 1:30 PM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2021 12:00:00 AM	3/2/2021 1:30 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2021 12:00:00 AM	3/2/2021 1:30 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	3/2/2021 1:30 PM
Details	State	Update	OPA Edit	Approved	Active	9/30/2020 3:13 PM
Dates	Start Date	Update	OPA Edit	10/1/2020 12:00:00 AM	9/30/2020 12:00:00 AM	9/30/2020 3:13 PM
Contacts	Signed By	Insert	New Registration		Cook, Jana Chief Financial Officer Phelps County Regional Medical Center 5734587916	9/30/2020 2:57 PM
Details	340B ID	Update	New Registration		SCH260017-02	9/30/2020 2:57 PM
Details	Entity Subname	Update	New Registration	Phelps Health Ambulatory Surgery Center	Phelps Health Ambulatory Surgery Center - Ambulatory Surgery	9/30/2020 2:57 PM
Dates	Participating Approval Date	Update	New Registration		9/30/2020 2:57:50 PM	9/30/2020 2:57 PM
Details	State	Update	New Registration	Pending	Approved	9/30/2020 2:57 PM
Dates	Signed By Date	Update	New Registration		9/30/2020 11:16:36 AM	9/30/2020 2:57 PM
Dates	Start Date	Update	New Registration		10/1/2020 12:00:00 AM	9/30/2020 2:57 PM
Addresses	Main Address	Insert	New Registration		1050 West 10th Street 2nd Floor Medical Office Building Rolla, MO 65401	9/24/2020 4:13 PM
Addresses	Billing Address	Insert	New Registration		Phelps Health 1000 West 10th Street Rolla, MO 65401	9/24/2020 4:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	9/24/2020 4:13 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010419109	9/24/2020 4:13 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	9/24/2020 4:13 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891766051	9/24/2020 4:13 PM
Medicaid Billing	NPI: State	Insert	New Registration		MO	9/24/2020 4:13 PM
Contacts	Primary Contact	Insert	New Registration		MOORE, KREIG Leland DIRECTOR OF PHARMACY Phelps County Regional Medical Center 5734587892	9/24/2020 4:13 PM
Contacts	Authorizing Official	Insert	New Registration		Cook, Jana Chief Financial Officer Phelps County Regional Medical Center 5734587916	9/24/2020 4:13 PM
Details	Assistance Received From Date	Insert	New Registration			9/24/2020 4:13 PM
Details	Assistance Received To Date	Insert	New Registration			9/24/2020 4:13 PM
Details	Last Recertification Date	Insert	New Registration			9/24/2020 4:13 PM
Details	Grant Number	Insert	New Registration			9/24/2020 4:13 PM
Details	340B ID	Insert	New Registration			9/24/2020 4:13 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			9/24/2020 4:13 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			9/24/2020 4:13 PM
Details	Medicare Provider Number	Insert	New Registration		260017	9/24/2020 4:13 PM
Details	Entity Name	Insert	New Registration		PHELPS COUNTY REGIONAL MEDICAL CNTR	9/24/2020 4:13 PM
Details	NOFO Number	Insert	New Registration			9/24/2020 4:13 PM
Details	Program Code	Insert	New Registration		SCH	9/24/2020 4:13 PM
Details	Entity Subname	Insert	New Registration		Phelps Health Ambulatory Surgery Center	9/24/2020 4:13 PM
Dates	Participating Approval Date	Insert	New Registration			9/24/2020 4:13 PM
Details	State	Insert	New Registration		Pending	9/24/2020 4:13 PM
Dates	Registration Date	Insert	New Registration		9/24/2020 4:13:19 PM	9/24/2020 4:13 PM
Dates	Signed By Date	Insert	New Registration			9/24/2020 4:13 PM
Dates	Start Date	Insert	New Registration			9/24/2020 4:13 PM
Terminations	Termination Comments	Insert	New Registration			9/24/2020 4:13 PM
Terminations	Termination Date	Insert	New Registration			9/24/2020 4:13 PM
Terminations	Termination Effective Date	Insert	New Registration			9/24/2020 4:13 PM
Terminations	Termination Reason	Insert	New Registration			9/24/2020 4:13 PM