Covered Entity Details

CAH161377-02 MercyOne Centerville Medical Center (Active) - information as of 5/26/2025 12:52:56 AM

Main Details

Name

MercyOne Centerville Medical Center

Subdivision Name

MERCY MEDICAL CENTER-CENTERVILLE - MercyOne Ottumwa Medical Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH161377-02

Medicare Provider Number

161377

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/12/2021

Participating Start Date

10/1/2021

Participating Approval Date

7/20/2021

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

MercyOne Centerville Medical Center
Nicole Clapp, President
(641) 437-3410

Primary Contact

Mercy Medical Center-Centerville
JEFF WILLIER, DIRECTOR OF PHARMACY
(641) 437-3442

Addresses

Street Address

522 N HANCOCK ST
MERCYONE OTTUMWA FAMILY AND INTERNAL MEDICINE CLIN
OTTUMWA, IA 52501-4231

Billing Address

MercyOne Centerville Medical Center
1 St Joseph Drive
Department of Pharmacy
Centerville, IA 52544

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?
No

Shipping Addresses

Shipping Address 1

MercyOne Centerville Medical Center
1 St Joseph Drive
Department of Pharmacy
Centerville, IA 52544

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
CAH161377-01	Child	CAH	MercyOne Centerville Medical Center	MERCY RURAL HEALTH CLINIC DBA MercyOne Centerville Medical Clinic	19942 ST. JOSEPH'S DRIVE	CENTERVILLE	IA	Active
CAH161377-02	Child	CAH	MercyOne Centerville Medical Center	MERCY MEDICAL CENTER-CENTERVILLE - MercyOne Ottumwa Medical Clinic	522 N HANCOCK ST	OTTUMWA	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/28/2023 2:49:18 PM	8/12/2024 5:21:37 PM	8/12/2024 5:21 PM
Details	Last Recertification Date	Update	Recertification	9/7/2022 11:05:38 AM	8/28/2023 2:49:18 PM	8/28/2023 2:49 PM
Contacts	Authorizing Official	Update	Change Request	Clapp, Nicole President MercyOne Centerville Medical Center 6414373410	Clapp, Nicole President MercyOne Centerville Medical Center 6414373410	6/20/2023 2:01 PM
Details	Last Recertification Date	Update	Recertification		9/7/2022 11:05:38 AM	9/7/2022 11:05 AM
Contacts	Authorizing Official	Update	Change Request	Young, Ann Vice President of Operations MeryOne Centerville Medical Center 6414373434	Clapp, Nicole President MercyOne Centerville Medical Center 6414373410	7/29/2022 11:20 AM
Contacts	Authorizing Official	Update	Change Request	Shull, Darren Director Healthcare Experience, Administration MercyOne Centerville Medical Center 6414373434	Young, Ann Vice President of Operations MeryOne Centerville Medical Center 6414373434	4/7/2022 4:04 PM
Contacts	Authorizing Official	Update	Change Request	JOHNSON, MATTHEW DONALD President MercyOne Centerville Medical Center 6414373411	Shull, Darren Director Healthcare Experience, Administration MercyOne Centerville Medical Center 6414373434	1/18/2022 3:10 PM
Addresses	Billing Address	Update	Change Request	MercyOne Centerville Medical Center 1 St Joseph Drive Centerville, IA 52544	MercyOne Centerville Medical Center 1 St Joseph Drive Department of Pharmacy Centerville, IA 52544	10/18/2021 7:59 AM
Addresses	Shipping Address	Insert	Change Request		MercyOne Centerville Medical Center 1 St Joseph Drive Department of Pharmacy Centerville, IA 52544	10/18/2021 7:59 AM
Details	State	Update		Approved	Active	10/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		JOHNSON, MATTHEW DONALD President MercyOne Centerville Medical Center 6414373411	7/20/2021 10:31 AM
Details	340B ID	Update	New Registration		CAH161377-02	7/20/2021 10:31 AM
Details	Entity Name	Update	New Registration	MERCY MEDICAL CENTER-CENTERVILLE	MercyOne Centerville Medical Center	7/20/2021 10:31 AM
Details	Entity Subname	Update	New Registration	MERCY MEDICAL CENTER-CENTERVILLE	MERCY MEDICAL CENTER-CENTERVILLE - MercyOne Ottumwa Medical Clinic	7/20/2021 10:31 AM
Dates	Participating Approval Date	Update	New Registration		7/20/2021 10:31:17 AM	7/20/2021 10:31 AM
Details	State	Update	New Registration	Pending	Approved	7/20/2021 10:31 AM
Dates	Signed By Date	Update	New Registration		7/13/2021 9:21:19 AM	7/20/2021 10:31 AM
Dates	Start Date	Update	New Registration		10/1/2021 12:00:00 AM	7/20/2021 10:31 AM
Addresses	Main Address	Insert	New Registration		522 N HANCOCK ST MERCYONE OTTUMWA FAMILY AND INTERNAL MEDICINE CLIN OTTUMWA, IA 52501-4231	7/12/2021 5:59 PM
Addresses	Billing Address	Insert	New Registration		MercyOne Centerville Medical Center 1 St Joseph Drive Centerville, IA 52544	7/12/2021 5:59 PM
Contacts	Primary Contact	Insert	New Registration		WILLIER, JEFF DIRECTOR OF PHARMACY Mercy Medical Center-Centerville 6414373442	7/12/2021 5:59 PM
Contacts	Authorizing Official	Insert	New Registration		JOHNSON, MATTHEW DONALD President MercyOne Centerville Medical Center 6414373411	7/12/2021 5:59 PM
Details	Assistance Received From Date	Insert	New Registration			7/12/2021 5:59 PM
Details	Assistance Received To Date	Insert	New Registration			7/12/2021 5:59 PM
Details	Last Recertification Date	Insert	New Registration			7/12/2021 5:59 PM
Details	Grant Number	Insert	New Registration			7/12/2021 5:59 PM
Details	340B ID	Insert	New Registration			7/12/2021 5:59 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/12/2021 5:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/12/2021 5:59 PM
Details	Medicare Provider Number	Insert	New Registration		161377	7/12/2021 5:59 PM
Details	Entity Name	Insert	New Registration		MERCY MEDICAL CENTER-CENTERVILLE	7/12/2021 5:59 PM
Details	NOFO Number	Insert	New Registration			7/12/2021 5:59 PM
Details	Program Code	Insert	New Registration		CAH	7/12/2021 5:59 PM
Details	Entity Subname	Insert	New Registration		MERCY MEDICAL CENTER-CENTERVILLE	7/12/2021 5:59 PM
Dates	Participating Approval Date	Insert	New Registration			7/12/2021 5:59 PM
Details	State	Insert	New Registration		Pending	7/12/2021 5:59 PM
Dates	Registration Date	Insert	New Registration		7/12/2021 5:59:57 PM	7/12/2021 5:59 PM
Dates	Signed By Date	Insert	New Registration			7/12/2021 5:59 PM
Dates	Start Date	Insert	New Registration			7/12/2021 5:59 PM
Terminations	Termination Comments	Insert	New Registration			7/12/2021 5:59 PM
Terminations	Termination Date	Insert	New Registration			7/12/2021 5:59 PM
Terminations	Termination Effective Date	Insert	New Registration			7/12/2021 5:59 PM
Terminations	Termination Reason	Insert	New Registration			7/12/2021 5:59 PM