Covered Entity Details

DSH370013J MERCY HOSPITAL OKC (Active) - information as of 5/1/2025 11:53:23 PM

Main Details

Name

MERCY HOSPITAL OKC

Subdivision Name

MERCY HOSPITAL OKLAHOMA CITY INC - PET Scan Coletta

Type

Disproportionate Share Hospital

Rural

340B ID

DSH370013J

Medicare Provider Number

370013

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/5/2022

Participating Start Date

11/4/2022

Participating Approval Date

10/19/2022

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Mercy
Christopher F Hahne, Vice President-Finance
(405) 936-5649

Primary Contact

Mercy Shared Services
Mike Loftus, Director-Hospital Pharmacy
(417) 820-3487

Addresses

Street Address

4401 MCAULEY BLVD
MERCY COLETTA BLDG-RADIATION ONCOLOGY
OKLAHOMA CITY, OK 73120-8341

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?
Yes

State	Medicaid Number	NPI Number
OK	100699390A	1184721722

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
DSH370013A	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - I-35 Diagnostic Radiology	2017W I 35 FRONTAGE RD 160	EDMOND	OK	Active
DSH370013B	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - I-35 Ultrasound	2017W I 35 FRONTAGE RD 160	EDMOND	OK	Active
DSH370013C	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - Oncology Infusion Coletta	4401 MCAULEY BLVD	OKLAHOMA CITY	OK	Active
DSH370013D	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - I-35 Surgery Center A	2017W I 35 FRONTAGE RD 160	EDMOND	OK	Active
DSH370013E	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - Radiation Therapy (Radiation Oncology/CT Scan Colletta)	4401 MCAULEY BLVD	OKLAHOMA CITY	OK	Active
DSH370013F	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - Hyperbaric/OP Wound	4140 W MEMORIAL RD STE 107	OKLAHOMA CITY	OK	Active
DSH370013G	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - I-35 CT Scan	2017W I 35 FRONTAGE RD 160	EDMOND	OK	Active
DSH370013H	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - I-35 MRI	2017W I 35 FRONTAGE RD 160	EDMOND	OK	Active
DSH370013J	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY INC - PET Scan Coletta	4401 MCAULEY BLVD	OKLAHOMA CITY	OK	Active
DSH370013K	Child	DSH	MERCY HOSPITAL OKC	MERCY EMERGENCY DEPARTMENT - EDMOND - I-35 Emergency Department	2301 W I-35 FRONTAGE RD	EDMOND	OK	Active
DSH370013L	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY-SOUTH - Oncology Infusion South	5200 E I 240 SERVICE RD	OKLAHOMA CITY	OK	Active
DSH370013M	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY-SOUTH - Ultrasound South	5200 E I 240 SERVICE RD	OKLAHOMA CITY	OK	Active
DSH370013N	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY-SOUTH - Operating Room South	5200 E I 240 SERVICE RD	OKLAHOMA CITY	OK	Active
DSH370013P	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY-SOUTH - Respiratory South	5200 E I 240 SERVICE RD	OKLAHOMA CITY	OK	Active
DSH370013Q	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY-SOUTH - CT Scan South	5200 E I 240 SERVICE RD	OKLAHOMA CITY	OK	Active
DSH370013R	Child	DSH	MERCY HOSPITAL OKC	MERCY EMERGENCY DEPARTMENT - EDMOND - Imaging I-35 (CT, Imaging Services, Ultrasound)	2301 W I-35 FRONTAGE RD	EDMOND	OK	Active
DSH370013S	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY-SOUTH - MRI South	5200 E I 240 SERVICE RD	OKLAHOMA CITY	OK	Active
DSH370013T	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY-SOUTH - Radiology South/Imaging	5200 E I 240 SERVICE RD	OKLAHOMA CITY	OK	Active
DSH370013U	Child	DSH	MERCY HOSPITAL OKC	MERCY HOSPITAL OKLAHOMA CITY-SOUTH - Adults and Pediatrics 6 South Medical Surgical	5200 E I 240 SERVICE RD	OKLAHOMA CITY	OK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	Loftus, Mike Director-Pharmacy Services Mercy 4178203487	Loftus, Mike Director-Hospital Pharmacy Mercy Shared Services 4178203487	8/26/2024 1:39 PM
Details	Last Recertification Date	Update	Recertification	8/18/2023 8:17:28 AM	8/26/2024 1:39:59 PM	8/26/2024 1:39 PM
Details	Last Recertification Date	Update	Recertification		8/18/2023 8:17:28 AM	8/18/2023 8:17 AM
Details	State	Update	OPA Edit	Approved	Active	11/4/2022 2:36 PM
Dates	Start Date	Update	OPA Edit	1/1/2023 12:00:00 AM	11/4/2022 12:00:00 AM	11/4/2022 2:36 PM
Contacts	Signed By	Insert	New Registration		Hahne, Christopher F Vice President-Finance Mercy 4059365649	10/19/2022 11:33 AM
Details	340B ID	Update	New Registration		DSH370013J	10/19/2022 11:33 AM
Details	Entity Subname	Update	New Registration	MERCY HOSPITAL OKLAHOMA CITY INC	MERCY HOSPITAL OKLAHOMA CITY INC - PET Scan Coletta	10/19/2022 11:33 AM
Dates	Participating Approval Date	Update	New Registration		10/19/2022 11:33:46 AM	10/19/2022 11:33 AM
Details	State	Update	New Registration	Pending	Approved	10/19/2022 11:33 AM
Dates	Signed By Date	Update	New Registration		10/7/2022 5:57:38 PM	10/19/2022 11:33 AM
Dates	Start Date	Update	New Registration		1/1/2023 12:00:00 AM	10/19/2022 11:33 AM
Addresses	Main Address	Insert	New Registration		4401 MCAULEY BLVD MERCY COLETTA BLDG-RADIATION ONCOLOGY OKLAHOMA CITY, OK 73120-8341	10/5/2022 8:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/5/2022 8:59 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100699390A	10/5/2022 8:59 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/5/2022 8:59 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1184721722	10/5/2022 8:59 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/5/2022 8:59 PM
Contacts	Primary Contact	Insert	New Registration		Loftus, Mike Director-Pharmacy Services Mercy 4178203487	10/5/2022 8:59 PM
Contacts	Authorizing Official	Insert	New Registration		Hahne, Christopher F Vice President-Finance Mercy 4059365649	10/5/2022 8:59 PM
Details	Assistance Received From Date	Insert	New Registration			10/5/2022 8:59 PM
Details	Assistance Received To Date	Insert	New Registration			10/5/2022 8:59 PM
Details	Last Recertification Date	Insert	New Registration			10/5/2022 8:59 PM
Details	Grant Number	Insert	New Registration			10/5/2022 8:59 PM
Details	340B ID	Insert	New Registration			10/5/2022 8:59 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/5/2022 8:59 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/5/2022 8:59 PM
Details	Medicare Provider Number	Insert	New Registration		370013	10/5/2022 8:59 PM
Details	Entity Name	Insert	New Registration		MERCY HOSPITAL OKC	10/5/2022 8:59 PM
Details	NOFO Number	Insert	New Registration			10/5/2022 8:59 PM
Details	Program Code	Insert	New Registration		DSH	10/5/2022 8:59 PM
Details	Entity Subname	Insert	New Registration		MERCY HOSPITAL OKLAHOMA CITY INC	10/5/2022 8:59 PM
Dates	Participating Approval Date	Insert	New Registration			10/5/2022 8:59 PM
Details	State	Insert	New Registration		Pending	10/5/2022 8:59 PM
Dates	Registration Date	Insert	New Registration		10/5/2022 8:59:19 PM	10/5/2022 8:59 PM
Dates	Signed By Date	Insert	New Registration			10/5/2022 8:59 PM
Dates	Start Date	Insert	New Registration			10/5/2022 8:59 PM
Terminations	Termination Comments	Insert	New Registration			10/5/2022 8:59 PM
Terminations	Termination Date	Insert	New Registration			10/5/2022 8:59 PM
Terminations	Termination Effective Date	Insert	New Registration			10/5/2022 8:59 PM
Terminations	Termination Reason	Insert	New Registration			10/5/2022 8:59 PM