Covered Entity Details

DSH160080C MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center (Active) - information as of 5/15/2025 2:01:33 AM

Main Details

Name

MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center

Subdivision Name

MERCYONE CLINTON MED CTR HLTH PLAZA - Internal Medicine

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH160080C

Medicare Provider Number

160080

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/2/2023

Participating Start Date

7/1/2023

Participating Approval Date

5/9/2023

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

MercyOne Clinton Medical Center
Mellissa Wood, COO/CNE
(563) 244-5608

Primary Contact

MercyOne North Iowa Medical Center
Erin Brownmiller, 340B Program Manager
(641) 428-7024

Addresses

Street Address

600 14TH AVE N
CLINTON, IA 52732-2914

Billing Address

MercyOne Clinton Medical Center
1410 North 4th Street
Clinton, IA 52732

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
DSH160080A	Child	DSH	MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center	CLINTON Renal Dialysis - Renal Dialysis	600 14th Ave N	Clinton	IA	Active
DSH160080B	Child	DSH	MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center	MERCYONE CLINTON WOUND CARE - Wound Care Clinic	600 14th Ave N	CLINTON	IA	Active
DSH160080C	Child	DSH	MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center	MERCYONE CLINTON MED CTR HLTH PLAZA - Internal Medicine	600 14TH AVE N	CLINTON	IA	Active
DSH160080D	Child	DSH	MERCY MEDICAL CENTER-CLINTON D/B/A MercyOne Clinton Medical Center	MERCYONE CLINTON MED CTR NORTH HEALTH PLAZA - ENT	915 13TH AVE NORTH	CLINTON	IA	Terminated
DSH160080E	Child	DSH	MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center	MercyOne Clinton Med Center Health Plaza - Nephrology	600 14th Avenue North	Clinton	IA	Active
DSH160080F	Child	DSH	MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center	MercyOne Clinton Ears, Nose and Throat Care - ENT	600 14th Ave N	Clinton	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Recertification	MERCY MEDICAL CENTER-CLINTON D/B/A MercyOne Clinton Medical Center	MERCY MEDICAL CENTER-CLINTON INC D/B/A MercyOne Clinton Medical Center	8/27/2024 4:05 PM
Addresses	Billing Address	Insert	Recertification		MercyOne Clinton Medical Center 1410 North 4th Street Clinton, IA 52732	8/27/2024 4:03 PM
Details	Last Recertification Date	Update	Recertification	8/15/2023 3:56:27 PM	8/27/2024 4:03:28 PM	8/27/2024 4:03 PM
Contacts	Primary Contact	Update	PC Change Request	Mathis, Adam 340B Program Coordinator MercyOne Siouxland Medical Center 7122792310	Brownmiller, Erin 340B Program Manager MercyOne North Iowa Medical Center 6414287024	1/17/2024 9:10 AM
Details	Last Recertification Date	Update	Recertification		8/15/2023 3:56:27 PM	8/15/2023 3:56 PM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Wood, Mellissa COO/CNE MercyOne Clinton Medical Center 5632445608	5/9/2023 8:51 AM
Details	340B ID	Update	New Registration		DSH160080C	5/9/2023 8:51 AM
Details	Entity Subname	Update	New Registration	MERCYONE CLINTON MED CTR HLTH PLAZA	MERCYONE CLINTON MED CTR HLTH PLAZA - Internal Medicine	5/9/2023 8:51 AM
Dates	Participating Approval Date	Update	New Registration		5/9/2023 8:51:29 AM	5/9/2023 8:51 AM
Details	State	Update	New Registration	Pending	Approved	5/9/2023 8:51 AM
Dates	Signed By Date	Update	New Registration		5/8/2023 12:30:20 PM	5/9/2023 8:51 AM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	5/9/2023 8:51 AM
Addresses	Main Address	Insert	New Registration		600 14TH AVE N CLINTON, IA 52732-2914	5/2/2023 1:44 PM
Contacts	Primary Contact	Insert	New Registration		Mathis, Adam 340B Program Coordinator MercyOne Siouxland Medical Center 7122792310	5/2/2023 1:44 PM
Contacts	Authorizing Official	Insert	New Registration		Wood, Mellissa COO/CNE MercyOne Clinton Medical Center 5632445608	5/2/2023 1:44 PM
Details	Assistance Received From Date	Insert	New Registration			5/2/2023 1:44 PM
Details	Assistance Received To Date	Insert	New Registration			5/2/2023 1:44 PM
Details	Last Recertification Date	Insert	New Registration			5/2/2023 1:44 PM
Details	Grant Number	Insert	New Registration			5/2/2023 1:44 PM
Details	340B ID	Insert	New Registration			5/2/2023 1:44 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			5/2/2023 1:44 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			5/2/2023 1:44 PM
Details	Medicare Provider Number	Insert	New Registration		160080	5/2/2023 1:44 PM
Details	Entity Name	Insert	New Registration		MERCY MEDICAL CENTER-CLINTON D/B/A MercyOne Clinton Medical Center	5/2/2023 1:44 PM
Details	NOFO Number	Insert	New Registration			5/2/2023 1:44 PM
Details	Program Code	Insert	New Registration		DSH	5/2/2023 1:44 PM
Details	Entity Subname	Insert	New Registration		MERCYONE CLINTON MED CTR HLTH PLAZA	5/2/2023 1:44 PM
Dates	Participating Approval Date	Insert	New Registration			5/2/2023 1:44 PM
Details	State	Insert	New Registration		Pending	5/2/2023 1:44 PM
Dates	Registration Date	Insert	New Registration		5/2/2023 1:44:57 PM	5/2/2023 1:44 PM
Dates	Signed By Date	Insert	New Registration			5/2/2023 1:44 PM
Dates	Start Date	Insert	New Registration			5/2/2023 1:44 PM
Terminations	Termination Comments	Insert	New Registration			5/2/2023 1:44 PM
Terminations	Termination Date	Insert	New Registration			5/2/2023 1:44 PM
Terminations	Termination Effective Date	Insert	New Registration			5/2/2023 1:44 PM
Terminations	Termination Reason	Insert	New Registration			5/2/2023 1:44 PM