| Contacts | Primary Contact | Update | New Registration | Brooks, Angela
Director of Pharmacy Services
Four Rivers Community Health Center
5735455934 | Brooks, Angela M
Director of Pharmacy Services
Four Rivers Community Health Center
5735455934 | 8/6/2024 9:38 PM |
| Details | State | Update | | To Be Terminated | Terminated | 4/1/2024 12:01 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Brooks, Angela
Pharmacy Programs Manager
Four Rivers Community Health Center
5735455934 | Brooks, Angela
Director of Pharmacy Services
Four Rivers Community Health Center
5735455934 | 1/15/2024 12:51 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 4/1/2024 12:00:00 AM | 1/3/2024 6:03 PM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 1/3/2024 6:03 PM |
| Terminations | Termination Comments | Update | Termination Request | | Dental only site- Will not use 340B inventory at this location | 1/3/2024 6:03 PM |
| Terminations | Termination Date | Update | Termination Request | | 4/1/2024 12:00:00 AM | 1/3/2024 6:03 PM |
| Terminations | Termination Effective Date | Update | Termination Request | | 4/1/2024 12:00:00 AM | 1/3/2024 6:03 PM |
| Terminations | Termination Reason | Update | Termination Request | | Never implemented the 340B Program | 1/3/2024 6:03 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Brooks, Angela
Pharmacy Programs Manager
Four Rivers Community Health Center
5732426311 | Brooks, Angela
Pharmacy Programs Manager
Four Rivers Community Health Center
5735455934 | 5/10/2023 5:10 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1164669172 (MO) | | 2/22/2023 2:56 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1538838560 (MO) | | 2/22/2023 2:56 PM |
| Details | Last Recertification Date | Update | Recertification | 2/28/2022 2:57:16 PM | 2/22/2023 2:56:26 PM | 2/22/2023 2:56 PM |
| Addresses | Billing Address | Update | Change Request | Your Community Health Center
1081 East 18th St
Rolla, MO 65401 | Four Rivers Community Health Center
1081 East 18th St
Rolla, MO 65401 | 10/5/2022 8:05 AM |
| Details | Entity Subname | Update | Change Request | Bourbon Dental | Bourbon Dental Clinic | 10/5/2022 8:05 AM |
| Medicaid Billing | NPI: Number | Insert | Group Change Request | | 1538838560 | 9/28/2022 9:03 AM |
| Medicaid Billing | NPI: State | Insert | Group Change Request | | MO | 9/28/2022 9:03 AM |
| Contacts | Authorizing Official | Update | Group Change Request | Gipson, Stuart
CEO
Four Rivers Community Health Center
5734266714 | Gipson, Stuart Hunter
CEO
South Central Missouri Community Health Center
4175767273 | 9/27/2022 12:09 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Gipson, Stuart
CEO
Your Community Health Center
5734266714 | Gipson, Stuart
CEO
Four Rivers Community Health Center
5734266714 | 9/21/2022 9:09 AM |
| Contacts | Signed By | Update | Profile Change Request | Gipson, Stuart
CEO
Your Community Health Center
5734266714 | Gipson, Stuart
CEO
Four Rivers Community Health Center
5734266714 | 9/21/2022 9:09 AM |
| Contacts | Primary Contact | Update | Recertification | Brooks, Angela
RPH
Your Community Health Center
5732426311 | Brooks, Angela
Pharmacy Programs Manager
Four Rivers Community Health Center
5732426311 | 2/28/2022 2:57 PM |
| Details | Last Recertification Date | Update | Recertification | | 2/28/2022 2:57:16 PM | 2/28/2022 2:57 PM |
| Details | State | Update | | Approved | Active | 1/1/2022 12:01 AM |
| Contacts | Signed By | Insert | New Registration | | Gipson, Stuart
CEO
Your Community Health Center
5734266714 | 10/15/2021 8:35 AM |
| Details | 340B ID | Update | New Registration | | CHC26564-06 | 10/15/2021 8:35 AM |
| Dates | Participating Approval Date | Update | New Registration | | 10/15/2021 8:35:03 AM | 10/15/2021 8:35 AM |
| Details | State | Update | New Registration | Pending | Approved | 10/15/2021 8:35 AM |
| Dates | Signed By Date | Update | New Registration | | 10/14/2021 5:03:05 PM | 10/15/2021 8:35 AM |
| Dates | Start Date | Update | New Registration | | 1/1/2022 12:00:00 AM | 10/15/2021 8:35 AM |
| Addresses | Main Address | Insert | New Registration | |
246 College St
Bourbon, MO 65441-8308 | 10/14/2021 4:13 PM |
| Addresses | Billing Address | Insert | New Registration | | Your Community Health Center
1081 East 18th St
Rolla, MO 65401 | 10/14/2021 4:13 PM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1164669172 | 10/14/2021 4:13 PM |
| Medicaid Billing | NPI: State | Insert | New Registration | | MO | 10/14/2021 4:13 PM |
| Contacts | Primary Contact | Insert | New Registration | | Brooks, Angela
RPH
Your Community Health Center
5732426311 | 10/14/2021 4:13 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Gipson, Stuart
CEO
Your Community Health Center
5734266714 | 10/14/2021 4:13 PM |
| Details | Assistance Received From Date | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Details | Assistance Received To Date | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Details | Grant Number | Insert | New Registration | | H80CS26564 | 10/14/2021 4:13 PM |
| Details | 340B ID | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Details | Medicare Provider Number | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Details | Entity Name | Insert | New Registration | | South Central Missouri Community Health Center | 10/14/2021 4:13 PM |
| Details | NOFO Number | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Details | Program Code | Insert | New Registration | | CH | 10/14/2021 4:13 PM |
| Details | Entity Subname | Insert | New Registration | | Bourbon Dental | 10/14/2021 4:13 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Details | State | Insert | New Registration | | Pending | 10/14/2021 4:13 PM |
| Dates | Registration Date | Insert | New Registration | | 10/14/2021 4:13:17 PM | 10/14/2021 4:13 PM |
| Dates | Signed By Date | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Dates | Start Date | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Terminations | Termination Date | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 10/14/2021 4:13 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 10/14/2021 4:13 PM |