Covered Entity Details

CAH161367-05 PELLA REGIONAL HEALTH CENTER (Active) - information as of 5/20/2025 11:37:33 PM

Main Details

Name

PELLA REGIONAL HEALTH CENTER

Subdivision Name

Pella Medical Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH161367-05

Medicare Provider Number

161367

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/6/2022

Participating Start Date

10/1/2022

Participating Approval Date

7/27/2022

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Pella Regional Health Center
Jody VanVeen, Chief Nursing and Chief Ancillary Officer
(641) 628-6629

Primary Contact

Pella Regional Health Center
Jessica Ann Rosenhamer, Pharmacy Director
(641) 628-6616

Addresses

Street Address

405 MONROE ST
PELLA REG MED CLINIC
PELLA, IA 50219-1189

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
CAH161367-01	Child	CAH	PELLA REGIONAL HEALTH CENTER	SULLY FAMILY HEALTH CENTER	704 3RD ST	SULLY	IA	Active
CAH161367-02	Child	CAH	PELLA REGIONAL HEALTH CENTER	MONROE FAMILY HEALTH CENTER	100 E. SHERMAN	MONROE	IA	Terminated
CAH161367-03	Child	CAH	PELLA REGIONAL HEALTH CENTER	Knoxville Family Health Center	1208 N LINCOLN	KNOXVILLE	IA	Active
CAH161367-04	Child	CAH	PELLA REGIONAL HEALTH CENTER	Ottumwa Medical Clinic	920 N Quincy Ave	Ottumwa	IA	Active
CAH161367-05	Child	CAH	PELLA REGIONAL HEALTH CENTER	Pella Medical Clinic	405 MONROE ST	PELLA	IA	Active
CAH161367-06	Child	CAH	PELLA REGIONAL HEALTH CENTER	PELLA REGIONAL HEALTH CENTER - PRAIRIE CITY MEDICAL CLINIC	404 E 2ND ST	PRAIRIE CITY	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Subname	Update	Change Request	PELLA REGIONAL HEALTH CENTER - Outpatient Clinic/Center Multi-Specialty	Pella Medical Clinic	1/10/2025 8:17 AM
Details	Last Recertification Date	Update	Recertification	8/18/2023 3:44:03 PM	8/13/2024 11:44:22 AM	8/13/2024 11:44 AM
Details	Last Recertification Date	Update	Recertification		8/18/2023 3:44:03 PM	8/18/2023 3:44 PM
Contacts	Primary Contact	Update	Group Change Request	Papineau, George Albert Director of Pharmacy Pella Regional Health Center 6416286616	Rosenhamer, Jessica Ann Pharmacy Director Pella Regional Health Center 6416286616	7/10/2023 6:59 AM
Details	State	Update		Approved	Active	10/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		VanVeen, Jody Chief Nursing and Chief Ancillary Officer Pella Regional Health Center 6416286629	7/27/2022 7:58 AM
Details	340B ID	Update	New Registration		CAH161367-05	7/27/2022 7:58 AM
Details	Entity Subname	Update	New Registration	PELLA REGIONAL HEALTH CENTER	PELLA REGIONAL HEALTH CENTER - Outpatient Clinic/Center Multi-Specialty	7/27/2022 7:58 AM
Dates	Participating Approval Date	Update	New Registration		7/27/2022 7:58:44 AM	7/27/2022 7:58 AM
Details	State	Update	New Registration	Pending	Approved	7/27/2022 7:58 AM
Dates	Signed By Date	Update	New Registration		7/13/2022 5:15:38 PM	7/27/2022 7:58 AM
Dates	Start Date	Update	New Registration		10/1/2022 12:00:00 AM	7/27/2022 7:58 AM
Addresses	Main Address	Insert	New Registration		405 MONROE ST PELLA REG MED CLINIC PELLA, IA 50219-1189	7/6/2022 12:23 PM
Contacts	Authorizing Official	Insert	New Registration		VanVeen, Jody Chief Nursing and Chief Ancillary Officer Pella Regional Health Center 6416286629	7/6/2022 12:23 PM
Contacts	Primary Contact	Insert	New Registration		Papineau, George Albert Director of Pharmacy Pella Regional Health Center 6416286616	7/6/2022 12:23 PM
Details	Assistance Received From Date	Insert	New Registration			7/6/2022 12:23 PM
Details	Assistance Received To Date	Insert	New Registration			7/6/2022 12:23 PM
Details	Last Recertification Date	Insert	New Registration			7/6/2022 12:23 PM
Details	Grant Number	Insert	New Registration			7/6/2022 12:23 PM
Details	340B ID	Insert	New Registration			7/6/2022 12:23 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/6/2022 12:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/6/2022 12:23 PM
Details	Medicare Provider Number	Insert	New Registration		161367	7/6/2022 12:23 PM
Details	Entity Name	Insert	New Registration		PELLA REGIONAL HEALTH CENTER	7/6/2022 12:23 PM
Details	NOFO Number	Insert	New Registration			7/6/2022 12:23 PM
Details	Program Code	Insert	New Registration		CAH	7/6/2022 12:23 PM
Details	Entity Subname	Insert	New Registration		PELLA REGIONAL HEALTH CENTER	7/6/2022 12:23 PM
Dates	Participating Approval Date	Insert	New Registration			7/6/2022 12:23 PM
Details	State	Insert	New Registration		Pending	7/6/2022 12:23 PM
Dates	Registration Date	Insert	New Registration		7/6/2022 12:23:55 PM	7/6/2022 12:23 PM
Dates	Signed By Date	Insert	New Registration			7/6/2022 12:23 PM
Dates	Start Date	Insert	New Registration			7/6/2022 12:23 PM
Terminations	Termination Comments	Insert	New Registration			7/6/2022 12:23 PM
Terminations	Termination Date	Insert	New Registration			7/6/2022 12:23 PM
Terminations	Termination Effective Date	Insert	New Registration			7/6/2022 12:23 PM
Terminations	Termination Reason	Insert	New Registration			7/6/2022 12:23 PM