Covered Entity Details

DSH160110J Allen Memorial Hospital Corporation (Active) - information as of 6/7/2025 4:36:33 AM

Main Details

Name

Allen Memorial Hospital Corporation

Subdivision Name

UnityPoint Health- Allen Hospital Cardiovascular Center - Cardiology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH160110J

Medicare Provider Number

160110

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/5/2023

Participating Start Date

1/1/2024

Participating Approval Date

10/11/2023

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Allen Memorial Hospital Corporation
Jennifer A Friedly, President
(319) 235-3997

Primary Contact

Allen Memorial Hospital Corporation
Natalie Arlene Hunter, VP Operations
(319) 235-3660

Addresses

Street Address

419 East Donald Street
Waterloo, IA 50703

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
IA	0601104	1336231091
IL		1336231091
WI		1336231091

Shipping Addresses

Shipping Address 1

Allen Memorial Hospital Corporation
1825 Logan Ave
Waterloo, IA 50703

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
DSH160110A	Child	DSH	Allen Memorial Hospital Corporation	Allen Hospital Pain Center	3630 West Fourth Street	Waterloo	IA	Active
DSH160110B	Child	DSH	Allen Memorial Hospital Corporation	Allen Hospital Ambulatory Surgery Center	1731 West Ridgeway	Waterloo	IA	Terminated
DSH160110C	Child	DSH	Allen Memorial Hospital Corporation	Allen Hospital Digestive Health Center	125 East Tower Park	Waterloo	IA	Terminated
DSH160110D	Child	DSH	Allen Memorial Hospital Corporation	ALLEN HOSPITAL COMMUNITY CANCER CENTER	3530 W 4TH ST.	WATERLOO	IA	Active
DSH160110E	Child	DSH	Allen Memorial Hospital Corporation	UNITY POINT HEALTH WATERLOO CENTER FOR UROLOGY	1717 W RIDGEWAY AVE	WATERLOO	IA	Terminated
DSH160110F	Child	DSH	Allen Memorial Hospital Corporation	Allen Memorial Hospital Community Cancer Center - Oncology Clinic	1753 W Ridgeway	Waterloo	IA	Terminated
DSH160110G	Child	DSH	Allen Memorial Hospital Corporation	Allen Memorial Hospital Infusion Center - Infusion Services	1731 W Ridgeway	Waterloo	IA	Terminated
DSH160110H	Child	DSH	Allen Memorial Hospital Corporation	Medication Management - UMP - Medication Management	1731 W Ridgeway	Waterloo	IA	Active
DSH160110J	Child	DSH	Allen Memorial Hospital Corporation	UnityPoint Health- Allen Hospital Cardiovascular Center - Cardiology	419 East Donald Street	Waterloo	IA	Active
DSH160110K	Child	DSH	Allen Memorial Hospital Corporation	UnityPoint Health- Allen Hospital Medication Management Clinic Cardiology - Medication Management	419 East Donald Street	Waterloo	IA	Active
DSH160110L	Child	DSH	Allen Memorial Hospital Corporation	Allen Memorial Hospital Infusion Center Department - Infusion	164 West Dale St	Waterloo	IA	Active
DSH160110M	Child	DSH	Allen Memorial Hospital Corporation	UnityPoint Health Allen Hospital Cardiovascular Center Ridgeway - Cardiovascular Clinic	2413 West Ridgeway Ave	Waterloo	IA	Active
DSH160110N	Child	DSH	Allen Memorial Hospital Corporation	UnityPoint Health Allen Hospital Pulmonology - Pulmonology	152 West Dale St	Waterloo	IA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Change Request		Allen Memorial Hospital Corporation 1825 Logan Ave Waterloo, IA 50703	10/9/2024 8:09 AM
Details	Last Recertification Date	Update	Recertification		8/13/2024 9:58:31 AM	8/13/2024 9:58 AM
Contacts	Primary Contact	Update	Profile Change Request	Hunter, Natalie Arlene Director Pharmacy Allen Memorial Hospital Corporation 3192353660	Hunter, Natalie Arlene VP Operations Allen Memorial Hospital Corporation 3192353660	7/11/2024 3:41 PM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Friedly, Jennifer A President Allen Memorial Hospital Corporation 3192353997	10/11/2023 10:18 AM
Details	340B ID	Update	New Registration		DSH160110J	10/11/2023 10:18 AM
Details	Entity Name	Update	New Registration	ALLEN MEMORIAL HOSPITAL	Allen Memorial Hospital Corporation	10/11/2023 10:18 AM
Details	Entity Subname	Update	New Registration	UnityPoint Health- Allen Hospital Cardiovascular Center	UnityPoint Health- Allen Hospital Cardiovascular Center - Cardiology	10/11/2023 10:18 AM
Dates	Participating Approval Date	Update	New Registration		10/11/2023 10:18:49 AM	10/11/2023 10:18 AM
Details	State	Update	New Registration	Pending	Approved	10/11/2023 10:18 AM
Dates	Signed By Date	Update	New Registration		10/11/2023 8:15:26 AM	10/11/2023 10:18 AM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	10/11/2023 10:18 AM
Contacts	Authorizing Official	Update	Profile Change Request	Friedly, Jennifer A Vice President/Chief Operating Officer Allen Memorial Hospital Corporation 3192353997	Friedly, Jennifer A President Allen Memorial Hospital Corporation 3192353997	10/10/2023 8:52 AM
Addresses	Main Address	Insert	New Registration		419 East Donald Street Waterloo, IA 50703	10/5/2023 1:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/5/2023 1:38 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0601104	10/5/2023 1:38 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IA	10/5/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1336231091	10/5/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	New Registration		IA	10/5/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1336231091	10/5/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/5/2023 1:38 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1336231091	10/5/2023 1:38 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	10/5/2023 1:38 PM
Contacts	Primary Contact	Insert	New Registration		Hunter, Natalie Arlene Director Pharmacy Allen Memorial Hospital Corporation 3192353660	10/5/2023 1:38 PM
Contacts	Authorizing Official	Insert	New Registration		Friedly, Jennifer A Vice President/Chief Operating Officer Allen Memorial Hospital Corporation 3192353997	10/5/2023 1:38 PM
Details	Assistance Received From Date	Insert	New Registration			10/5/2023 1:38 PM
Details	Assistance Received To Date	Insert	New Registration			10/5/2023 1:38 PM
Details	Last Recertification Date	Insert	New Registration			10/5/2023 1:38 PM
Details	Grant Number	Insert	New Registration			10/5/2023 1:38 PM
Details	340B ID	Insert	New Registration			10/5/2023 1:38 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/5/2023 1:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/5/2023 1:38 PM
Details	Medicare Provider Number	Insert	New Registration		160110	10/5/2023 1:38 PM
Details	Entity Name	Insert	New Registration		ALLEN MEMORIAL HOSPITAL	10/5/2023 1:38 PM
Details	NOFO Number	Insert	New Registration			10/5/2023 1:38 PM
Details	Program Code	Insert	New Registration		DSH	10/5/2023 1:38 PM
Details	Entity Subname	Insert	New Registration		UnityPoint Health- Allen Hospital Cardiovascular Center	10/5/2023 1:38 PM
Dates	Participating Approval Date	Insert	New Registration			10/5/2023 1:38 PM
Details	State	Insert	New Registration		Pending	10/5/2023 1:38 PM
Dates	Registration Date	Insert	New Registration		10/5/2023 1:38:56 PM	10/5/2023 1:38 PM
Dates	Signed By Date	Insert	New Registration			10/5/2023 1:38 PM
Dates	Start Date	Insert	New Registration			10/5/2023 1:38 PM
Terminations	Termination Comments	Insert	New Registration			10/5/2023 1:38 PM
Terminations	Termination Date	Insert	New Registration			10/5/2023 1:38 PM
Terminations	Termination Effective Date	Insert	New Registration			10/5/2023 1:38 PM
Terminations	Termination Reason	Insert	New Registration			10/5/2023 1:38 PM