Covered Entity Details

DSH260137BS FREEMAN HEALTH SYSTEM (Active) - information as of 5/20/2025 11:44:23 PM

Main Details

Name

FREEMAN HEALTH SYSTEM

Subdivision Name

FREEMAN OAK HILL HEALTH SYSTEM - PHYSICIAN GROUP OF PITTSBURG

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH260137BS

Medicare Provider Number

260137

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/6/2021

Participating Start Date

1/1/2022

Participating Approval Date

10/18/2021

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Freeman Health System
Jeff Thompson, Chief Clinical Officer
(417) 347-3563

Primary Contact

Freeman Health System
Greg Cobble, Director of Retail Pharmacy Operations
(417) 347-3078

Addresses

Street Address

1201 E CENTENNIAL DR
PITTSBURG, KS 66762-6623

Billing Address

FREEMAN HEALTH SYSTEM
1102 W 32ND ST
JOPLIN, MO 64804

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	010565208,508364106,606699502,540565207,506033406,500037217	1114394228,1174637953,1265546048,1679517023,1790743698,1891809679
OK	100693570A,100711500O,100707160P,100846850A	1114394228,1174637953,1265546048,1679517023,1790743698,1891809679
KS	30003901280002,30003901280118,30003901280006,30003901280001	1114394228,1174637953,1265546048,1679517023,1790743698,1891809679

Shipping Addresses

Shipping Address 1

FREEMAN HEALTH SYSTEM
1102 W 32ND ST
JOPLIN, MO 64804

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
DSH260137AA	Child	DSH	FREEMAN HEALTH SYSTEM	PRIMARY CARE	1636 S MADISON ST	WEBB CITY	MO	Active
DSH260137AB	Child	DSH	FREEMAN HEALTH SYSTEM	FAMILY MEDICINE ASSOCIATES	702 E 34TH ST	JOPLIN	MO	Active
DSH260137AC	Child	DSH	FREEMAN HEALTH SYSTEM	SOUTHWEST INTERNAL MEDICINE	3202 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137AD	Child	DSH	FREEMAN HEALTH SYSTEM	AKUNA FAMILY MEDICINE	1020 MCINTOSH CIR	JOPLIN	MO	Terminated
DSH260137AF	Child	DSH	FREEMAN HEALTH SYSTEM	FREEMAN HEART & VASCULAR INSTITUTE	1102 W 32ND ST	JOPLIN	MO	Active
DSH260137AG	Child	DSH	FREEMAN HEALTH SYSTEM	FREEMAN HEART & VASCULAR INSTITUTE	1102 W 32ND ST	JOPLIN	MO	Active
DSH260137AH	Child	DSH	FREEMAN HEALTH SYSTEM	FAMILY MEDICINE	3202 MCINTOSH CIR	JOPLIN	MO	Terminated
DSH260137AK	Child	DSH	FREEMAN HEALTH SYSTEM	PEDIATRIC PARTNERS	1030 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137AL	Child	DSH	FREEMAN HEALTH SYSTEM	CHILDREN'S CLINIC	1030 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137AM	Child	DSH	FREEMAN HEALTH SYSTEM	EAR, NOSE & THROAT CENTER	1331 W 32ND ST	JOPLIN	MO	Active
DSH260137AN	Child	DSH	FREEMAN HEALTH SYSTEM	ORTHOPAEDICS AND SPORTS MEDICINE	3105 MCCLELLAND BLVD	JOPLIN	MO	Active
DSH260137AP	Child	DSH	FREEMAN HEALTH SYSTEM	UROLOGY ASSOCIATES	3401 MCINTOSH CIRCLE	JOPLIN	MO	Active
DSH260137AQ	Child	DSH	FREEMAN HEALTH SYSTEM	Freeman Health System Neurology	1002 McIntosh Cir	JOPLIN	MO	Active
DSH260137AR	Child	DSH	FREEMAN HEALTH SYSTEM	BUCHELE SURGICAL SERVICES	1020 MCINTOSH CIR	JOPLIN	MO	Terminated
DSH260137AS	Child	DSH	FREEMAN HEALTH SYSTEM	SURGICAL ASSOCIATES	1020 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137AT	Child	DSH	FREEMAN HEALTH SYSTEM	GENERAL & VASCULAR SURGICAL GROUP	3302 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137AU	Child	DSH	FREEMAN HEALTH SYSTEM	PAIN MANAGEMENT CENTER	3103 MCCLELLAND BLVD	JOPLIN	MO	Terminated
DSH260137AV	Child	DSH	FREEMAN HEALTH SYSTEM	CENTER FOR DIGESTIVE HEALTH	3333 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137AW	Child	DSH	FREEMAN HEALTH SYSTEM	FREEMAN HEART & VASCULAR INSTITUTE	3333 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137AX	Child	DSH	FREEMAN HEALTH SYSTEM	INFECTIOUS DISEASES	3315 McIntosh Cir.	JOPLIN	MO	Active
DSH260137AY	Child	DSH	FREEMAN HEALTH SYSTEM	Renal Dialysis	932 East 34th Street	Joplin	MO	Active
DSH260137AZ	Child	DSH	FREEMAN HEALTH SYSTEM	Freeman Kidney Center	932 East 34th St	Joplin	MO	Active
DSH260137B	Child	DSH	FREEMAN HEALTH SYSTEM	CORNELL-BESHORE CANCER INSTITUTE	3415 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137BA	Child	DSH	FREEMAN HEALTH SYSTEM	CARL JUNCTION FAMILY MEDICINE	104 S MAIN ST	CARL JUNCTION	MO	Active
DSH260137BB	Child	DSH	FREEMAN HEALTH SYSTEM	OUTPATIENT DIALYSIS CENTER	1636 S MADISON ST	WEBB CITY	MO	Active
DSH260137BC	Child	DSH	FREEMAN HEALTH SYSTEM	FREEMAN HEART & VASCULAR INSTITUTE	1500 S CASE ST	CARTHAGE	MO	Active
DSH260137BD	Child	DSH	FREEMAN HEALTH SYSTEM	ORTHOPAEDICS & SPORTS MEDICINE	1500 S CASE ST	CARTHAGE	MO	Active
DSH260137BE	Child	DSH	FREEMAN HEALTH SYSTEM	OB/GYN ASSOCIATES	1500 S CASE ST	CARTHAGE	MO	Terminated
DSH260137BF	Child	DSH	FREEMAN HEALTH SYSTEM	CLINIC OF CARTHAGE	719 WEST CENTENNIAL	CARTHAGE	MO	Active
DSH260137BG	Child	DSH	FREEMAN HEALTH SYSTEM	CLINIC OF BAXTER SPRINGS	322 E 11TH ST	BAXTER SPRINGS	KS	Active
DSH260137BH	Child	DSH	FREEMAN HEALTH SYSTEM	CORNELL-BESHORE CANCER INSTITUTE	932 E 34TH ST	JOPLIN	MO	Active
DSH260137BJ	Child	DSH	FREEMAN HEALTH SYSTEM	SENECA FAMILY MEDICINE	1606 OLIVE ST	SENECA	MO	Active
DSH260137BK	Child	DSH	FREEMAN HEALTH SYSTEM	Lamar Family Care	307 W 11th St	Lamar	MO	Active
DSH260137BL	Child	DSH	FREEMAN HEALTH SYSTEM	FIRST CARE - First Care	3202 MCINTOSH CIR	JOPLIN	MO	Terminated
DSH260137BM	Child	DSH	FREEMAN HEALTH SYSTEM	Rheumatology - Premier Clinic - Rheumatology	931 E 32nd St	Joplin	MO	Active
DSH260137BN	Child	DSH	FREEMAN HEALTH SYSTEM	Lithotripsy - Lithotripsy East Campus	3105 McClelland BLVD	Joplin	MO	Terminated
DSH260137BP	Child	DSH	FREEMAN HEALTH SYSTEM	Endoscopy - Endoscopy East Campus	932 East 34th St	Joplin	MO	Active
DSH260137BQ	Child	DSH	FREEMAN HEALTH SYSTEM	Gastroenterology	1020 McIntosh Cir	Joplin	MO	Active
DSH260137BR	Child	DSH	FREEMAN HEALTH SYSTEM	Pain Management - Pain Management East Campus	932 East 34th St	Joplin	MO	Active
DSH260137BS	Child	DSH	FREEMAN HEALTH SYSTEM	FREEMAN OAK HILL HEALTH SYSTEM - PHYSICIAN GROUP OF PITTSBURG	1201 E CENTENNIAL DR	PITTSBURG	KS	Active
DSH260137BT	Child	DSH	FREEMAN HEALTH SYSTEM	SLEEP CENTER	931 E 32ND ST	JOPLIN	MO	Active
DSH260137BU	Child	DSH	FREEMAN HEALTH SYSTEM	BROWNING INTERNAL MEDICINE	3202 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137BV	Child	DSH	FREEMAN HEALTH SYSTEM	DERMATOLOGY AND SKIN CANCER CENTER	3401 MCINTOSH CIRCLE	JOPLIN	MO	Active
DSH260137BW	Child	DSH	FREEMAN HEALTH SYSTEM	INSTITUTE FOR PAIN MANAGEMENT - INSTITUTE FOR PAIN MANAGEMENT - SANDERS	3333 McIntosh Circle	JOPLIN	MO	Active
DSH260137BX	Child	DSH	FREEMAN HEALTH SYSTEM	Neurospine - Neurology and Headache Clinic	1020 McIntosh Circle, Suite 200	Joplin	MO	Active
DSH260137BY	Child	DSH	FREEMAN HEALTH SYSTEM	ACUTE CARE SURGERY CLINIC - ACUTE CARE SURGERY CLINIC	1020 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137BZ	Child	DSH	FREEMAN HEALTH SYSTEM	ACADEMIC FAMILY MEDICINE - ACADEMIC FAMILY MEDICINE	3202 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137C	Child	DSH	FREEMAN HEALTH SYSTEM	Kidney Center	932 EAST 34TH STREET	JOPLIN	MO	Terminated
DSH260137CA	Child	DSH	FREEMAN HEALTH SYSTEM	ADVANCED SURGICAL PRACTICE - ADVANCED SURGICAL PRACTICE	1020 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137CB	Child	DSH	FREEMAN HEALTH SYSTEM	NEUROSPINE - Freeman NeuroSpine-Neurology	3401 MCINTOSH CIR	JOPLIN	MO	Approved
DSH260137F	Child	DSH	FREEMAN HEALTH SYSTEM	FREEMAN MIDWEST SURGERY	3105 MCCLELLAND BLVD	JOPLIN	MO	Active
DSH260137G	Child	DSH	FREEMAN HEALTH SYSTEM	WEBB CITY URGENT CARE	1636 S. MADISON ST	WEBB CITY	MO	Active
DSH260137H	Child	DSH	FREEMAN HEALTH SYSTEM	URGENT CARE	1130 E. 32ND ST	JOPLIN	MO	Active
DSH260137K	Child	DSH	FREEMAN HEALTH SYSTEM	Freeman Cancer Institute Grove	601 E. 13th Street	Grove	OK	Terminated
DSH260137L	Child	DSH	FREEMAN HEALTH SYSTEM	Academic Internal Medicine	3202 McIntosh Circle	Joplin	MO	Active
DSH260137M	Child	DSH	FREEMAN HEALTH SYSTEM	CENTER FOR GERIATRIC MEDICINE	931 E. 32nd St	Joplin	MO	Active
DSH260137N	Child	DSH	FREEMAN HEALTH SYSTEM	WOUND CARE & HYPERBARIC MEDICINE	3315 McIntosh Cir	Joplin	MO	Active
DSH260137P	Child	DSH	FREEMAN HEALTH SYSTEM	Freeman East Procedural and Recovery	932 E 34th St	JOPLIN	MO	Active
DSH260137Q	Child	DSH	FREEMAN HEALTH SYSTEM	PERINATOLOGY CENTER	1532 W 32ND ST	JOPLIN	MO	Active
DSH260137R	Child	DSH	FREEMAN HEALTH SYSTEM	Women's Healthcare Associates	1532 W 32ND ST	JOPLIN	MO	Active
DSH260137S	Child	DSH	FREEMAN HEALTH SYSTEM	OZARK OBSTETRICS & GYNECOLOGY	1532 W 32ND ST	JOPLIN	MO	Active
DSH260137T	Child	DSH	FREEMAN HEALTH SYSTEM	OB/GYN ASSOCIATES	1532 W 32ND ST	JOPLIN	MO	Active
dsH260137U	Child	DSH	FREEMAN HEALTH SYSTEM	DIABETES & ENDOCRINE INSTITUTE	1532 W 32ND ST	JOPLIN	MO	Active
DSH260137V	Child	DSH	FREEMAN HEALTH SYSTEM	Lung Institute	1002 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137W	Child	DSH	FREEMAN HEALTH SYSTEM	PEDIATRIC CARE	3333 MCINTOSH CIR	JOPLIN	MO	Terminated
DSH260137X	Child	DSH	FREEMAN HEALTH SYSTEM	ESGUERRA PEDIATRIC CLINIC	702 E 34TH ST	JOPLIN	MO	Terminated
DSH260137Y	Child	DSH	FREEMAN HEALTH SYSTEM	FAMILY PRACTICE	3202 MCINTOSH CIR	JOPLIN	MO	Active
DSH260137Z	Child	DSH	FREEMAN HEALTH SYSTEM	Southwest Family Medicine	3202 MCINTOSH CIR	JOPLIN	MO	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Recertification	50037217 (MO)		9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100099600A (KS)		9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100283460D (KS)		9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100099600G (KS)		9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100283460F (KS)		9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	30003901280004 (KS)		9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		500037217	9/3/2024 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/3/2024 11:10 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100846850A	9/3/2024 11:10 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/3/2024 11:10 AM
Details	Last Recertification Date	Update	Recertification	9/1/2023 12:33:39 PM	9/3/2024 11:10:51 AM	9/3/2024 11:10 AM
Details	Last Recertification Date	Update	Recertification	9/6/2022 10:12:48 AM	9/1/2023 12:33:39 PM	9/1/2023 12:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		30003901280002	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KS	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		30003901280118	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KS	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		30003901280004	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KS	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		30003901280006	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KS	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		30003901280001	12/19/2022 1:47 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		KS	12/19/2022 1:47 PM
Details	Last Recertification Date	Update	Recertification		9/6/2022 10:12:48 AM	9/6/2022 10:12 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/6/2022 1:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100283460F	1/6/2022 1:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	1/6/2022 1:46 PM
Details	State	Update		Approved	Active	1/1/2022 12:01 AM
Contacts	Primary Contact	Update	Group Change Request	Thompson, Jeff Chief Clinical Officer Freeman Health System 4173473563	Cobble, Greg Director of Retail Pharmacy Operations Freeman Health System 4173473078	12/30/2021 6:32 AM
Contacts	Authorizing Official	Update	Change Request	GRADDY, STEVE CFO Freeman Health System 4173476678	Thompson, Jeff Chief Clinical Officer Freeman Health System 4173473563	10/22/2021 7:30 AM
Contacts	Primary Contact	Update	Profile Change Request	Thompson, Jeff VP Pharmacy Services Freeman Health System 4173473563	Thompson, Jeff Chief Clinical Officer Freeman Health System 4173473563	10/21/2021 4:33 PM
Contacts	Signed By	Insert	New Registration		GRADDY, STEVE CFO Freeman Health System 4173476678	10/18/2021 7:56 AM
Details	340B ID	Update	New Registration		DSH260137BS	10/18/2021 7:56 AM
Details	Entity Name	Update	New Registration	FREEMAN OAK HILL HEALTH SYSTEM	FREEMAN HEALTH SYSTEM	10/18/2021 7:56 AM
Details	Entity Subname	Update	New Registration	FREEMAN OAK HILL HEALTH SYSTEM	FREEMAN OAK HILL HEALTH SYSTEM - PHYSICIAN GROUP OF PITTSBURG	10/18/2021 7:56 AM
Dates	Participating Approval Date	Update	New Registration		10/18/2021 7:56:53 AM	10/18/2021 7:56 AM
Details	State	Update	New Registration	Pending	Approved	10/18/2021 7:56 AM
Dates	Signed By Date	Update	New Registration		10/15/2021 11:43:28 AM	10/18/2021 7:56 AM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	10/18/2021 7:56 AM
Addresses	Main Address	Insert	New Registration		1201 E CENTENNIAL DR PITTSBURG, KS 66762-6623	10/6/2021 9:42 AM
Addresses	Billing Address	Insert	New Registration		FREEMAN HEALTH SYSTEM 1102 W 32ND ST JOPLIN, MO 64804	10/6/2021 9:42 AM
Addresses	Shipping Address	Insert	New Registration		FREEMAN HEALTH SYSTEM 1102 W 32ND ST JOPLIN, MO 64804	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010565208	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		50037217	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		508364106	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		606699502	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		540565207	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		506033406	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100099600A	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100283460D	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100099600G	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100693570A	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100711500O	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100707160P	10/6/2021 9:42 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1114394228	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174637953	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1265546048	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1679517023	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1790743698	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1891809679	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		MO	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1114394228	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174637953	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1265546048	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1679517023	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1790743698	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1891809679	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		KS	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1114394228	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174637953	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1265546048	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1679517023	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1790743698	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1891809679	10/6/2021 9:42 AM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/6/2021 9:42 AM
Contacts	Primary Contact	Insert	New Registration		Thompson, Jeff VP Pharmacy Services Freeman Health System 4173473563	10/6/2021 9:42 AM
Contacts	Authorizing Official	Insert	New Registration		GRADDY, STEVE CFO Freeman Health System 4173476678	10/6/2021 9:42 AM
Details	Assistance Received From Date	Insert	New Registration			10/6/2021 9:42 AM
Details	Assistance Received To Date	Insert	New Registration			10/6/2021 9:42 AM
Details	Last Recertification Date	Insert	New Registration			10/6/2021 9:42 AM
Details	Grant Number	Insert	New Registration			10/6/2021 9:42 AM
Details	340B ID	Insert	New Registration			10/6/2021 9:42 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/6/2021 9:42 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/6/2021 9:42 AM
Details	Medicare Provider Number	Insert	New Registration		260137	10/6/2021 9:42 AM
Details	Entity Name	Insert	New Registration		FREEMAN OAK HILL HEALTH SYSTEM	10/6/2021 9:42 AM
Details	NOFO Number	Insert	New Registration			10/6/2021 9:42 AM
Details	Program Code	Insert	New Registration		DSH	10/6/2021 9:42 AM
Details	Entity Subname	Insert	New Registration		FREEMAN OAK HILL HEALTH SYSTEM	10/6/2021 9:42 AM
Dates	Participating Approval Date	Insert	New Registration			10/6/2021 9:42 AM
Details	State	Insert	New Registration		Pending	10/6/2021 9:42 AM
Dates	Registration Date	Insert	New Registration		10/6/2021 9:42:37 AM	10/6/2021 9:42 AM
Dates	Signed By Date	Insert	New Registration			10/6/2021 9:42 AM
Dates	Start Date	Insert	New Registration			10/6/2021 9:42 AM
Terminations	Termination Comments	Insert	New Registration			10/6/2021 9:42 AM
Terminations	Termination Date	Insert	New Registration			10/6/2021 9:42 AM
Terminations	Termination Effective Date	Insert	New Registration			10/6/2021 9:42 AM
Terminations	Termination Reason	Insert	New Registration			10/6/2021 9:42 AM