Covered Entity Details

SCH260195-04 CITIZENS MEMORIAL HOSPITAL DISTRICT (Terminated) - information as of 4/23/2025 11:58:34 PM

Main Details

Name

CITIZENS MEMORIAL HOSPITAL DISTRICT

Subdivision Name

Southside Medical Center - Southside Medical Center

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH260195-04

Medicare Provider Number

260195

Outpatient Facility Provider Number

268668

Additional Details

Current Program Status

Terminated

Registration Date

10/1/2021

Participating Start Date

11/1/2021

Participating Approval Date

11/1/2021

Last Recertification Date

Termination Date
Termination Reason

4/1/2022
Change of covered entity type

Contacts

Authorizing Official

Citizens Memorial Hospital
Renee Marie Meyer, Chief Financial Officer
(417) 328-6258

Primary Contact

Citizens Memorial Hospital District
Tim Wolters, Director of Reimbursement
(417) 328-7286

Addresses

Street Address

1120 South Springfield Avenue
Bolivar, MO 65613

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?
No

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
SCH260195-01	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Surgical Services - CMH Surgical Services	1155 West Parkview Street, Suite 1F	Bolivar	MO	Terminated
SCH260195-02	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Humansville Family Medical Center - Humansville Family Medical Center	201 South Arthur	Humansville	MO	Terminated
SCH260195-03	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Infusion Center - CMH Infusion Center	1155 West Parkview Street, Suite 2M	Bolivar	MO	Terminated
SCH260195-04	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Southside Medical Center - Southside Medical Center	1120 South Springfield Avenue	Bolivar	MO	Terminated
SCH260195-05	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Osceola Medical Center - Osceola Medical Center	855 Arduser Drive	Osceola	MO	Terminated
SCH260195-06	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Dallas County Family Medical Center - Dallas County Family Medical Center	201 South Ash	Buffalo	MO	Terminated
SCH260195-07	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	El Dorado Springs Medical Center - El Dorado Springs Medical Center	322 East Hospital Road	El Dorado Springs	MO	Terminated
SCH260195-08	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Infectious Disease Clinic - CMH Infectious Disease Clinic	1155 West Parkview Street, Suite 1G	Bolivar	MO	Terminated
SCH260195-09	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Ash Grove Family Medical Center - Ash Grove Family Medical Center	500 North Medical Drive	Ash Grove	MO	Terminated
SCH260195-10	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Rheumatology and Osteoporosis Center - CMH Rheumatology and Osteoporosis Center	1155 West Parkview Street, Suite 2K	Bolivar	MO	Terminated
SCH260195-11	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Ambulatory Surgery Center - Ambulatory Surgery Center	1155 West Parkview Street	Bolivar	MO	Terminated
SCH260195-12	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Wound and Hyperbaric Center - CMH Wound and Hyperbaric Center	1155 West Parkview Street, Suite 1G	Bolivar	MO	Terminated
SCH260195-13	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Heart Institute Clinic - CMH Heart Institute Clinic	1500 North Oakland	Bolivar	MO	Terminated
SCH260195-14	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Neurology Clinic - CMH Neurology Clinic	1245 North Butterfield Road	Bolivar	MO	Terminated
SCH260195-15	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Specialty Clinic - CMH Specialty Clinic	1155 West Parkview Street, Suite 2J	Bolivar	MO	Terminated
SCH260195-16	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Gastroenterology Clinic - Gastroenterology Clinic	1155 West Parkview Street, Suite 1F	Bolivar	MO	Terminated
SCH260195-17	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Dade County Family Medical Center - Dade County Family Medical Center	105 North Grand, Suite 2	Greenfield	MO	Terminated
SCH260195-18	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Stockton Family Medical Center - Stockton Family Medical Center	1521 South Third Street	Stockton	MO	Terminated
SCH260195-19	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Walk-In Clinic - CMH Walk-In Clinic	2230 South Springfield, Suite H-J	Bolivar	MO	Terminated
SCH260195-20	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Pleasant Hope Family Medical Center - Pleasant Hope Family Medical Center	209 South Main Street	Pleasant Hope	MO	Terminated
SCH260195-21	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Butterfield Park Medical Center - Butterfield Park Medical Center	1300 North Oakland	Bolivar	MO	Terminated
SCH260195-22	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH OB/GYN and Pediatric Clinic - CMH OB/GYN and Pediatric Clinic	1195 North Oakland	Bolivar	MO	Terminated
SCH260195-23	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Institute of Pain Management - CMH Institute of Pain Management	1155 West Parkview Street, Suite 1C	Bolivar	MO	Terminated
SCH260195-24	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Pulmonology Clinic - CMH Pulmonology Clinic	1165 North Butterfield Road	Bolivar	MO	Terminated
SCH260195-25	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	CMH Urology Surgical Clinic - CMH Urology Surgical Clinic	1155 West Parkview Street, Suite 2C	Bolivar	MO	Terminated
SCH260195-26	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Bolivar Family Care Center - Bolivar Family Care Center	1240 North Butterfield	Bolivar	MO	Terminated
SCH260195-27	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Ambulance - CMH Hickory County Ambulance Service	US Highway 54 & Highway 254	Hermitage	MO	Terminated
SCH260195-28	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Ambulance - CMH St. Clair County Ambulance Service	700 Giesler Road	Osceola	MO	Terminated
SCH260195-29	Child	SCH	CITIZENS MEMORIAL HOSPITAL DISTRICT	Ambulance - CMH Polk County Ambulance Service	1551 North Oakland	Bolivar	MO	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Terminate		4/1/2022 12:00:00 AM	3/25/2022 5:33 PM
Details	State	Update	OPA Terminate	Active	To Be Terminated	3/25/2022 5:33 PM
Terminations	Termination Date	Update	OPA Terminate		4/1/2022 12:00:00 AM	3/25/2022 5:33 PM
Terminations	Termination Effective Date	Update	OPA Terminate		4/1/2022 12:00:00 AM	3/25/2022 5:33 PM
Terminations	Termination Reason	Update	OPA Terminate		Change of covered entity type	3/25/2022 5:33 PM
Details	State	Update	OPA Edit	Approved	Active	11/1/2021 10:48 AM
Dates	Start Date	Update	OPA Edit	1/1/2022 12:00:00 AM	11/1/2021 12:00:00 AM	11/1/2021 10:48 AM
Contacts	Signed By	Insert	New Registration		Meyer, Renee Marie Chief Financial Officer Citizens Memorial Hospital 4173286258	11/1/2021 10:47 AM
Details	340B ID	Update	New Registration		SCH260195-04	11/1/2021 10:47 AM
Details	Entity Subname	Update	New Registration	Southside Medical Center	Southside Medical Center - Southside Medical Center	11/1/2021 10:47 AM
Dates	Participating Approval Date	Update	New Registration		11/1/2021 10:47:14 AM	11/1/2021 10:47 AM
Details	State	Update	New Registration	Pending	Approved	11/1/2021 10:47 AM
Dates	Signed By Date	Update	New Registration		10/4/2021 1:09:45 PM	11/1/2021 10:47 AM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	11/1/2021 10:47 AM
Addresses	Main Address	Insert	New Registration		1120 South Springfield Avenue Bolivar, MO 65613	10/1/2021 5:23 PM
Contacts	Primary Contact	Insert	New Registration		Wolters, Tim Director of Reimbursement Citizens Memorial Hospital District 4173287286	10/1/2021 5:23 PM
Contacts	Authorizing Official	Insert	New Registration		Meyer, Renee Marie Chief Financial Officer Citizens Memorial Hospital 4173286258	10/1/2021 5:23 PM
Details	Assistance Received From Date	Insert	New Registration			10/1/2021 5:23 PM
Details	Assistance Received To Date	Insert	New Registration			10/1/2021 5:23 PM
Details	Last Recertification Date	Insert	New Registration			10/1/2021 5:23 PM
Details	Grant Number	Insert	New Registration			10/1/2021 5:23 PM
Details	340B ID	Insert	New Registration			10/1/2021 5:23 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/1/2021 5:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/1/2021 5:23 PM
Details	Medicare Provider Number	Insert	New Registration		260195	10/1/2021 5:23 PM
Details	Entity Name	Insert	New Registration		CITIZENS MEMORIAL HOSPITAL DISTRICT	10/1/2021 5:23 PM
Details	NOFO Number	Insert	New Registration			10/1/2021 5:23 PM
Details	Program Code	Insert	New Registration		SCH	10/1/2021 5:23 PM
Details	Entity Subname	Insert	New Registration		Southside Medical Center	10/1/2021 5:23 PM
Dates	Participating Approval Date	Insert	New Registration			10/1/2021 5:23 PM
Details	State	Insert	New Registration		Pending	10/1/2021 5:23 PM
Dates	Registration Date	Insert	New Registration		10/1/2021 5:23:19 PM	10/1/2021 5:23 PM
Dates	Signed By Date	Insert	New Registration			10/1/2021 5:23 PM
Dates	Start Date	Insert	New Registration			10/1/2021 5:23 PM
Terminations	Termination Comments	Insert	New Registration			10/1/2021 5:23 PM
Terminations	Termination Date	Insert	New Registration			10/1/2021 5:23 PM
Terminations	Termination Effective Date	Insert	New Registration			10/1/2021 5:23 PM
Terminations	Termination Reason	Insert	New Registration			10/1/2021 5:23 PM