Covered Entity Details

SCH140064-07 ST. MARY MEDICAL CENTER (Approved) - information as of 4/29/2025 1:40:22 AM

Main Details

Name

ST. MARY MEDICAL CENTER

Subdivision Name

OSF CANCER CENTER - OSF Cancer Center Galesburg

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH140064-07

Medicare Provider Number

140064

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/14/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/16/2025

Last Recertification Date

Contacts

Authorizing Official

OSF HealthCare
Sandra Salverson, SVP Pharmacy Services
(309) 624-8817

Primary Contact

OSF Healthcare
amy krantz, Manager Strategic Reimbursement
(309) 655-2865

Addresses

Street Address

3375 N SEMINARY ST
GALESBURG, IL 61401-1251

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
IL		1164485363

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
SCH140064-01	Child	SCH	ST. MARY MEDICAL CENTER	ST MARY MEDICAL CENTER - OSF Healthcare Medical Group Abingdon	100 N MONROE ST	ABINGDON	IL	Active
SCH140064-02	Child	SCH	ST. MARY MEDICAL CENTER	ST MARY MEDICAL CENTER - OSF Healthcare Medical Group Knoxville	904 E MAIN ST	KNOXVILLE	IL	Active
SCH140064-03	Child	SCH	ST. MARY MEDICAL CENTER	ST MARY MEDICAL CENTER - OSF Healthcare Medical Group Galesburg	3315 N SEMINARY ST	GALESBURG	IL	Active
SCH140064-04	Child	SCH	ST. MARY MEDICAL CENTER	ST MARY MEDICAL CENTER - OSF Healthcare Prompt Care Galesburg	695 N KELLOGG ST	GALESBURG	IL	Active
SCH140064-05	Child	SCH	ST. MARY MEDICAL CENTER	OSF SAINT MARY MEDICAL CENTER - OSF Healthcare Medical Group Seminary	834 N SEMINARY ST	GALESBURG	IL	Active
SCH140064-06	Child	SCH	ST. MARY MEDICAL CENTER	ST MARY MEDICAL CENTER - Center for Outpatient Services	3333 N SEMINARY ST	GALESBURG	IL	Active
SCH140064-07	Child	SCH	ST. MARY MEDICAL CENTER	OSF CANCER CENTER - OSF Cancer Center Galesburg	3375 N SEMINARY ST	GALESBURG	IL	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	4/16/2025 2:56 PM
Details	340B ID	Update	New Registration		SCH140064-07	4/16/2025 2:56 PM
Details	Entity Subname	Update	New Registration	OSF CANCER CENTER	OSF CANCER CENTER - OSF Cancer Center Galesburg	4/16/2025 2:56 PM
Dates	Participating Approval Date	Update	New Registration		4/16/2025 2:56:15 PM	4/16/2025 2:56 PM
Details	State	Update	New Registration	Pending	Approved	4/16/2025 2:56 PM
Dates	Signed By Date	Update	New Registration		4/16/2025 9:42:18 AM	4/16/2025 2:56 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/16/2025 2:56 PM
Addresses	Main Address	Insert	New Registration		3375 N SEMINARY ST GALESBURG, IL 61401-1251	4/14/2025 3:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1164485363	4/14/2025 3:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	4/14/2025 3:57 PM
Contacts	Primary Contact	Insert	New Registration		krantz, amy Manager Strategic Reimbursement OSF Healthcare 3096552865	4/14/2025 3:57 PM
Contacts	Authorizing Official	Insert	New Registration		Salverson, Sandra SVP Pharmacy Services OSF HealthCare 3096248817	4/14/2025 3:57 PM
Details	Assistance Received From Date	Insert	New Registration			4/14/2025 3:57 PM
Details	Assistance Received To Date	Insert	New Registration			4/14/2025 3:57 PM
Details	Last Recertification Date	Insert	New Registration			4/14/2025 3:57 PM
Details	Grant Number	Insert	New Registration			4/14/2025 3:57 PM
Details	340B ID	Insert	New Registration			4/14/2025 3:57 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/14/2025 3:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/14/2025 3:57 PM
Details	Medicare Provider Number	Insert	New Registration		140064	4/14/2025 3:57 PM
Details	Entity Name	Insert	New Registration		ST. MARY MEDICAL CENTER	4/14/2025 3:57 PM
Details	NOFO Number	Insert	New Registration			4/14/2025 3:57 PM
Details	Program Code	Insert	New Registration		SCH	4/14/2025 3:57 PM
Details	Entity Subname	Insert	New Registration		OSF CANCER CENTER	4/14/2025 3:57 PM
Dates	Participating Approval Date	Insert	New Registration			4/14/2025 3:57 PM
Details	State	Insert	New Registration		Pending	4/14/2025 3:57 PM
Dates	Registration Date	Insert	New Registration		4/14/2025 3:57:28 PM	4/14/2025 3:57 PM
Dates	Signed By Date	Insert	New Registration			4/14/2025 3:57 PM
Dates	Start Date	Insert	New Registration			4/14/2025 3:57 PM
Terminations	Termination Comments	Insert	New Registration			4/14/2025 3:57 PM
Terminations	Termination Date	Insert	New Registration			4/14/2025 3:57 PM
Terminations	Termination Effective Date	Insert	New Registration			4/14/2025 3:57 PM
Terminations	Termination Reason	Insert	New Registration			4/14/2025 3:57 PM