| Details | Last Recertification Date | Update | Recertification | 1/29/2024 10:14:51 AM | 2/13/2025 12:31:11 PM | 2/13/2025 12:31 PM |
| Details | Grant Number | Update | Recertification | 5 H30MC24047-12-00 | H30MC24047 | 2/13/2025 12:31 PM |
| Contacts | Authorizing Official | Update | Change Request | Brewer, David
Administrative Director - Metro Acute Care Finance
Promedica Health System
5675850257 | Hageman, Andrew James
Finance Director
ProMedica
5675850990 | 5/14/2024 12:40 PM |
| Details | Last Recertification Date | Update | Recertification | 2/15/2023 8:58:04 AM | 1/29/2024 10:14:51 AM | 1/29/2024 10:14 AM |
| Contacts | Primary Contact | Update | PC Change Request | Trimbath, Christopher
Director 340B Program
ProMedica Health System
5675851760 | Ribley, Devan Matthew
Lead 340B Analyst
Promedica Health Systems
5675850154 | 1/18/2024 10:31 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Fought, Scott
CFO, Providers, Acute & Ambulatory Care
Toledo Hospital
5675855909 | Brewer, David
Administrative Director - Metro Acute Care Finance
Promedica Health System
5675850257 | 8/21/2023 12:53 PM |
| Addresses | Shipping Address | Delete | Change Request | DBA Promedica Specialty Pharmacy
2100 W Central Ave
STE 140
Toledo, OH 43606-3817 | | 6/7/2023 2:31 PM |
| Addresses | Shipping Address | Insert | Change Request | | The Toledo Hospital
2142 North Cove Blvd
Toledo, OH 43606 | 6/7/2023 2:31 PM |
| Details | Grant Number | Update | Change Request | 2 H30MC24047-11-00 | 5 H30MC24047-12-00 | 6/7/2023 2:31 PM |
| Details | Last Recertification Date | Update | Recertification | 2/25/2022 2:04:48 PM | 2/15/2023 8:58:04 AM | 2/15/2023 8:58 AM |
| Details | Grant Number | Update | Recertification | 5H30MC24047-10-00 | 2 H30MC24047-11-00 | 2/15/2023 8:58 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/20/2022 4:22 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 0999675 | 10/20/2022 4:22 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OH | 10/20/2022 4:22 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/20/2022 4:22 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1555780 | 10/20/2022 4:22 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | MI | 10/20/2022 4:22 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 10/20/2022 4:22 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 5172625 | 10/20/2022 4:22 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | MI | 10/20/2022 4:22 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1205837259 | 10/20/2022 4:22 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | OH | 10/20/2022 4:22 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1407854771 | 10/20/2022 4:22 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MI | 10/20/2022 4:22 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1205837259 | 10/20/2022 4:22 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MI | 10/20/2022 4:22 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1093804783 | 10/20/2022 4:22 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MI | 10/20/2022 4:22 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Trimbath, Christopher
340B Program Manager
ProMedica Health System
5675851760 | Trimbath, Christopher
Director 340B Program
ProMedica Health System
5675851760 | 10/7/2022 3:11 PM |
| Details | Last Recertification Date | Update | Recertification | 2/22/2021 2:25:29 PM | 2/25/2022 2:04:48 PM | 2/25/2022 2:04 PM |
| Details | Grant Number | Update | Recertification | 5H30MC24047-07-00 | 5H30MC24047-10-00 | 2/25/2022 2:04 PM |
| Addresses | Shipping Address | Insert | Change Request | | DBA Promedica Specialty Pharmacy #2
2109 Hughes Dr Conrad Jobst Tower
840
Toledo, OH 43606-3856 | 8/4/2021 2:16 PM |
| Addresses | Shipping Address | Insert | Change Request | | DBA Promedica Specialty Pharmacy
2100 W Central Ave
STE 140
Toledo, OH 43606-3817 | 8/4/2021 2:16 PM |
| Contacts | Primary Contact | Update | Change Request | Ohler, Sue
Director, NWO Hemophilia Center
The Toledo Hospital
4192917884 | Trimbath, Christopher
340B Program Manager
ProMedica Health System
5675851760 | 6/22/2021 6:56 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | OH | 2/22/2021 2:25 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | OH | 2/22/2021 2:25 PM |
| Details | Last Recertification Date | Update | Recertification | 2/14/2020 7:47:39 AM | 2/22/2021 2:25:29 PM | 2/22/2021 2:25 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Fought, Scott
VP Finance - Acute Care
Toledo Hospital
4192915909 | Fought, Scott
CFO, Providers, Acute & Ambulatory Care
Toledo Hospital
5675855909 | 2/18/2021 6:47 AM |
| Details | Last Recertification Date | Update | Recertification | 2/11/2019 9:05:54 AM | 2/14/2020 7:47:39 AM | 2/14/2020 7:47 AM |
| Details | Last Recertification Date | Update | Recertification | 2/26/2018 5:46:37 PM | 2/11/2019 9:05:54 AM | 2/11/2019 9:05 AM |
| Addresses | Main Address | Update | Change Request |
2150 West Central Ave.
Suite K
Toledo, OH 43606 |
2109 Hughes Drive
Conrad Jobst Tower
Suite 860
Toledo, OH 43606 | 7/13/2018 9:57 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 7/13/2018 9:57 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 8822662 | 7/13/2018 9:57 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | OH | 7/13/2018 9:57 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1093804783 | 7/13/2018 9:57 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1407854771 | 7/13/2018 9:57 AM |
| Details | Grant Number | Update | Change Request | H30MC00015 | 5H30MC24047-07-00 | 7/13/2018 9:57 AM |
| Details | Last Recertification Date | Update | Recertification | 2/20/2017 12:00:00 AM | 2/26/2018 5:46:37 PM | 2/26/2018 5:46 PM |
| Contacts | Primary Contact | Update | Recertification | Ohler, Sue
Director, NWO Hemophilia Center
4192917884 | Ohler, Sue
Director, NWO Hemophilia Center
The Toledo Hospital
4192917884 | 2/26/2018 5:46 PM |
| Contacts | Authorizing Official | Update | | Fought, Scott
VP Finance - Acute Care
4192915909 | Fought, Scott
VP Finance - Acute Care
Toledo Hospital
4192915909 | 10/17/2017 5:25 PM |
| Contacts | Authorizing Official | Insert | | | Fought, Scott
VP Finance - Acute Care
4192915909 | 7/12/2017 5:53 PM |
| Addresses | Main Address | Insert | | |
2150 West Central Ave.
Suite K
Toledo, OH 43606 | 2/20/2017 8:08 AM |
| Contacts | Primary Contact | Insert | | | Ohler, Sue
Director, NWO Hemophilia Center
4192917884 | 2/20/2017 8:08 AM |
| Details | Last Recertification Date | Update | | 3/8/2016 12:00:00 AM | 2/20/2017 12:00:00 AM | 2/20/2017 8:07 AM |
| Medicaid Billing | Medicaid: Is Primary | Update | | True | False | 3/8/2016 8:54 AM |
| Details | Last Recertification Date | Update | | 2/16/2015 12:00:00 AM | 3/8/2016 12:00:00 AM | 3/8/2016 8:54 AM |
| Details | Last Recertification Date | Update | | 3/10/2014 12:00:00 AM | 2/16/2015 12:00:00 AM | 2/16/2015 10:07 PM |
| Addresses | Billing Address | Insert | | | The Toledo Hospital
2142 North Cove Blvd.
Toledo, OH 43606 | 3/10/2014 1:33 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/10/2014 12:00:00 AM | 3/10/2014 1:33 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/19/2013 11:00 AM |
| Details | Grant Number | Update | | | H30MC00015 | 1/30/2013 3:28 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | True | 7/1/1995 12:00 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 0105497 | 7/1/1995 12:00 AM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 7/1/1995 12:00 AM |
| Details | Last Recertification Date | Insert | | | | 7/1/1995 12:00 AM |
| Details | Grant Number | Insert | | | | 7/1/1995 12:00 AM |
| Details | 340B ID | Insert | | | HM11574 | 7/1/1995 12:00 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/1/1995 12:00 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/1/1995 12:00 AM |
| Details | Medicare Provider Number | Insert | | | | 7/1/1995 12:00 AM |
| Details | Entity Name | Insert | | | THE TOLEDO HOSPITAL | 7/1/1995 12:00 AM |
| Details | Program Code | Insert | | | HM | 7/1/1995 12:00 AM |
| Details | Entity Subname | Insert | | | NORTHWEST OHIO HEMOPHILIA TREATMENT CTR | 7/1/1995 12:00 AM |
| Dates | Participating Approval Date | Insert | | | 7/1/1995 12:00:00 AM | 7/1/1995 12:00 AM |
| Details | State | Insert | | | Active | 7/1/1995 12:00 AM |
| Dates | Registration Date | Insert | | | 7/1/1995 12:00:00 AM | 7/1/1995 12:00 AM |
| Dates | Signed By Date | Insert | | | | 7/1/1995 12:00 AM |
| Dates | Start Date | Insert | | | 7/1/1995 12:00:00 AM | 7/1/1995 12:00 AM |
| Terminations | Termination Comments | Insert | | | | 7/1/1995 12:00 AM |
| Terminations | Termination Date | Insert | | | | 7/1/1995 12:00 AM |
| Terminations | Termination Effective Date | Insert | | | | 7/1/1995 12:00 AM |
| Terminations | Termination Reason | Insert | | | | 7/1/1995 12:00 AM |