Covered Entity Details

DSH370047B MERCY HOSPITAL ARDMORE (Active) - information as of 5/6/2025 11:11:32 PM

Main Details

Name

MERCY HOSPITAL ARDMORE

Subdivision Name

MERCY CANCER CENTER ADRMORE - Mercy Cancer Center Ardmore

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH370047B

Medicare Provider Number

370047

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/9/2023

Participating Start Date

1/1/2024

Participating Approval Date

11/6/2023

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Mercy
Tammi Harmoning, Chief Financial Officer
(479) 338-2267

Primary Contact

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

Addresses

Street Address

1220 HALL PLACE
ARDMORE, OK 73401

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	100262320C	1386741635

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
DSH370047A	Child	DSH	MERCY HOSPITAL ARDMORE	MERCY HOSPITAL PAIN MANAGEMENT - Pain Management	731 12TH NWAVE 302	ARDMORE	OK	Active
DSH370047B	Child	DSH	MERCY HOSPITAL ARDMORE	MERCY CANCER CENTER ADRMORE - Mercy Cancer Center Ardmore	1220 HALL PLACE	ARDMORE	OK	Active
DSH370047C	Child	DSH	MERCY HOSPITAL ARDMORE	MERCY HOSPITAL ARDMORE INC - Mercy Hyperbaric and Wound Care	1001 12TH AVE NW	ARDMORE	OK	Active
DSH370047D	Child	DSH	MERCY HOSPITAL ARDMORE	MERCY HEART AND VASCULAR ARDMORE - Cardio	731 12TH AVE NW	ARDMORE	OK	Active
DSH370047E	Child	DSH	MERCY HOSPITAL ARDMORE	MERCY CANCER CENTER ADRMORE - ARDMORE PET CT	1220 HALL PLACE	ARDMORE	OK	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Bruner, Marcus Executive Director Finance Mercy Hospital Ardmore 580-220-6239 and Mercy Hospital Ada 580-421-6128 5802206239	Harmoning, Tammi Chief Financial Officer Mercy 4793382267	3/12/2025 3:40 PM
Contacts	Primary Contact	Update	Recertification	Loftus, Mike Director-Pharmacy Services Mercy 4178203487	Loftus, Mike Director-Hospital Pharmacy Mercy Shared Services 4178203487	8/28/2024 10:00 AM
Details	Last Recertification Date	Update	Recertification		8/28/2024 10:00:37 AM	8/28/2024 10:00 AM
Contacts	Authorizing Official	Update	Change Request	Hahne, Christopher F Vice President-Finance Mercy 4059365649	Bruner, Marcus Executive Director Finance Mercy Hospital Ardmore 580-220-6239 and Mercy Hospital Ada 580-421-6128 5802206239	4/12/2024 2:36 PM
Contacts	Authorizing Official	Update	Change Request	Brown, Morris W. Executive Director - Finance Mercy 5804216128	Hahne, Christopher F Vice President-Finance Mercy 4059365649	1/8/2024 7:14 AM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Brown, Morris W. Executive Director - Finance Mercy 5804216128	11/6/2023 9:48 AM
Details	340B ID	Update	New Registration		DSH370047B	11/6/2023 9:48 AM
Details	Entity Subname	Update	New Registration	MERCY CANCER CENTER ADRMORE	MERCY CANCER CENTER ADRMORE - Mercy Cancer Center Ardmore	11/6/2023 9:48 AM
Dates	Participating Approval Date	Update	New Registration		11/6/2023 9:48:16 AM	11/6/2023 9:48 AM
Details	State	Update	New Registration	Pending	Approved	11/6/2023 9:48 AM
Dates	Signed By Date	Update	New Registration		10/11/2023 2:28:22 PM	11/6/2023 9:48 AM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	11/6/2023 9:48 AM
Addresses	Main Address	Insert	New Registration		1220 HALL PLACE ARDMORE, OK 73401	10/9/2023 12:05 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/9/2023 12:05 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100262320C	10/9/2023 12:05 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OK	10/9/2023 12:05 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1386741635	10/9/2023 12:05 PM
Medicaid Billing	NPI: State	Insert	New Registration		OK	10/9/2023 12:05 PM
Contacts	Primary Contact	Insert	New Registration		Loftus, Mike Director-Pharmacy Services Mercy 4178203487	10/9/2023 12:05 PM
Contacts	Authorizing Official	Insert	New Registration		Brown, Morris W. Executive Director - Finance Mercy 5804216128	10/9/2023 12:05 PM
Details	Assistance Received From Date	Insert	New Registration			10/9/2023 12:05 PM
Details	Assistance Received To Date	Insert	New Registration			10/9/2023 12:05 PM
Details	Last Recertification Date	Insert	New Registration			10/9/2023 12:05 PM
Details	Grant Number	Insert	New Registration			10/9/2023 12:05 PM
Details	340B ID	Insert	New Registration			10/9/2023 12:05 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/9/2023 12:05 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/9/2023 12:05 PM
Details	Medicare Provider Number	Insert	New Registration		370047	10/9/2023 12:05 PM
Details	Entity Name	Insert	New Registration		MERCY HOSPITAL ARDMORE	10/9/2023 12:05 PM
Details	NOFO Number	Insert	New Registration			10/9/2023 12:05 PM
Details	Program Code	Insert	New Registration		DSH	10/9/2023 12:05 PM
Details	Entity Subname	Insert	New Registration		MERCY CANCER CENTER ADRMORE	10/9/2023 12:05 PM
Dates	Participating Approval Date	Insert	New Registration			10/9/2023 12:05 PM
Details	State	Insert	New Registration		Pending	10/9/2023 12:05 PM
Dates	Registration Date	Insert	New Registration		10/9/2023 12:05:47 PM	10/9/2023 12:05 PM
Dates	Signed By Date	Insert	New Registration			10/9/2023 12:05 PM
Dates	Start Date	Insert	New Registration			10/9/2023 12:05 PM
Terminations	Termination Comments	Insert	New Registration			10/9/2023 12:05 PM
Terminations	Termination Date	Insert	New Registration			10/9/2023 12:05 PM
Terminations	Termination Effective Date	Insert	New Registration			10/9/2023 12:05 PM
Terminations	Termination Reason	Insert	New Registration			10/9/2023 12:05 PM