Covered Entity Details

DSH140191 INGALLS MEMORIAL HOSPITAL (Active) - information as of 6/21/2025 12:03:32 AM

Main Details

Name

INGALLS MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140191

Medicare Provider Number

140191

Additional Details

Current Program Status

Active

Registration Date

9/22/2005

Participating Start Date

9/22/2005

Participating Approval Date

9/22/2005

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

The University of Chicago Medical Center
Denise Scarpelli, Vice President, Chief Pharmacy Officer
(773) 834-5601

Primary Contact

Ingalls Memorial Hospital
TOM SAMEK, ASSISTANT GENERAL COUNSEL
(773) 702-4405

Addresses

Street Address

ONE INGALLS DRIVE
HARVEY, IL 60426

Billing Address

Ingalls Memorial Hospital
150 Harvester Drive
Suite 300
Burr Ridge, IL 60527

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		1598756686,1841387388
IN		1598756686,1841387388
WI		1598756686
CO		1598756686
IA		1598756686

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/15/2021	07/01/2021		07/01/2021
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/15/2021	07/01/2021	10/01/2023	01/24/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/15/2021	07/01/2021	10/01/2023	01/24/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/15/2021	07/01/2021		07/01/2021
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/15/2021	07/01/2021	07/20/2023	10/12/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/15/2021	07/01/2021	10/01/2023	01/24/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	03/01/2022	04/01/2022		04/01/2022
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02558	14700 HALSTED ST	HARVEY	IL	60426	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03179	820 183RD ST	HOMEWOOD	IL	60430	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03651	20950 GOVERNORS HWY.	OLYMPIA FIELDS	IL	60461	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03928	18301 PULASKI AVE	HAZEL CREST	IL	60429	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04148	7960 W. 159TH ST.	ORLAND PARK	IL	60462	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #21247	15940 KEDZIE AVE	MARKHAM	IL	60428-4017	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04532	15 S. ORCHARD DR.	PARK FOREST	IL	60466	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04743	16675 OAK PARK AVE	TINLEY PARK	IL	60477	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04947	13501 CICERO AVE	CRESTWOOD	IL	60418-1934	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04949	7209 W. LINCOLN HWY.	FRANKFORT	IL	60423	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05086	3120 CHICAGO RD	SOUTH CHICAGO HEIGHTS	IL	60411	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05104	5525 159TH ST	OAK FOREST	IL	60452	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05126	3564 RIDGE RD	LANSING	IL	60438	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05127	18133 TORRENCE AVE	LANSING	IL	60438	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05128	2601 E SAUK TRL	SAUK VILLAGE	IL	60411	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05193	3145 W 147TH ST	POSEN	IL	60469	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05355	650 DIXIE HWY	CHICAGO HEIGHTS	IL	60411	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #09331	8400 171ST STREET	TINLEY PARK	IL	60487	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 11109	4800 148TH STREET	MIDLOTHIAN	IL	60445-3117	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 11224	11981 W 143RD ST	ORLAND PARK	IL	60467	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04032	466 NELSON ROAD	NEW LENOX	IL	60451	04/16/2015	07/01/2015	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04154	20002 WOLF RD	MOKENA	IL	60448	04/16/2015	07/01/2015	08/09/2019	08/09/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04336	1401 WESTERN AVE.	CHICAGO HEIGHTS	IL	60411	04/16/2015	07/01/2015	10/20/2016	11/02/2016
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/07/2021	10/01/2021	11/08/2021	01/12/2022
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	04/15/2021	07/01/2021	12/08/2022	12/08/2022
Contract Detail	INGALLS HEALTH VENTURES	1551 HUNTINGTON DR STE A		CALUMET CITY	IL	60409	11/29/2021	11/29/2021	06/30/2024	09/04/2024
Contract Detail	INGALLS MEMORIAL HOSPITAL	ATTN: DEPT OF PHARMACY SERVICE	1 INGALLS DR	HARVEY	IL	60426-3558	07/17/2017	10/01/2017	04/13/2020	04/15/2020
Contract Detail	INGALLS PROFESSIONAL PHARM II	6701 W 159TH ST		TINLEY PARK	IL	60477	10/22/2012	10/22/2012	02/02/2016	02/02/2016
Contract Detail	INGALLS PROFESSIONAL PHARMACY	19550 GOVERNORS HWY		FLOSSMOOR	IL	60422	10/22/2012	10/22/2012	02/02/2016	02/02/2016
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	04/15/2021	07/01/2021	12/08/2022	12/08/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/15/2021	07/01/2021	12/08/2022	12/08/2022
Contract Detail	OPTUM PHARMACY 705, LLC	11142 RENNER BLVD		LENEXA	KS	66219	04/15/2021	07/01/2021	07/01/2021	07/13/2021
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/15/2021	07/01/2021	12/08/2022	12/08/2022
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/15/2021	07/01/2021	12/08/2022	12/08/2022
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/13/2021	10/01/2021	12/08/2022	12/08/2022
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/07/2021	10/01/2021	11/08/2021	01/12/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/13/2017	10/01/2017	08/30/2019	09/13/2019
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/15/2021	07/01/2021	01/15/2024	01/15/2024
Contract Detail	UCM SERVICES CORPORATION	DBA INGALLS PROFESSIONAL PHARMACY	71 W 156TH ST STE 104 INGALLS PROFESSIONAL	HARVEY	IL	60426	10/22/2012	10/22/2012	02/02/2016	02/02/2016
Contract Detail	UCM SERVICES CORPORATION	DBA INGALLS PROFESSIONAL PHARMACY	71 W 156TH ST STE 104 INGALLS PROFESSIONAL	HARVEY	IL	60426	07/16/2018	10/01/2018		10/01/2018
Contract Detail	UNIVERSITY OF CHICAGO DCAM OUTPATIENT PH	5758 S. MARYLAND AVE.	MC0010	CHICAGO	IL	60637-1426	07/17/2017	10/01/2017		10/01/2017
Contract Detail	UNIVERSITY OF CHICAGO MEDICAL CENTER	DBA UCMC PHARMACY SERVICES	1551 HUNTINGTON DR STE B	CALUMET CITY	IL	60409	10/15/2021	10/15/2021		10/15/2021
Contract Detail	WALGREEN CO	DBA: WALGREENS #10937	5640 211TH ST	MATTESON	IL	60443	04/16/2015	07/01/2015	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO	DBA: WALGREENS #15525	201 E. HURON STREET, SUITE 01-210	CHICAGO	IL	60611	07/13/2017	10/01/2017	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05786	4889 SAUK TRAIL	RICHTON PARK	IL	60471	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06332	1150 E SIBLEY BLVD	DOLTON	IL	60419-2828	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06564	522 TORRENCE AVE	CALUMET CITY	IL	60409	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06580	14680 S LA GRANGE ROAD	ORLAND PARK	IL	60462-3287	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09330	18300 GOVERNORS HWY	HOMEWOOD	IL	60430-2910	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09924	390 EAST 162ND STREET	SOUTH HOLLAND	IL	60473-0241	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10485	12854 S ASHLAND AVE	CALUMET PARK	IL	60827-6308	01/13/2014	04/01/2014	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02054	626 RIVER OAKS DR	CALUMET CITY	IL	60409	04/16/2015	07/01/2015	04/19/2016	04/20/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06762	11833 S WESTERN AVE	CHICAGO	IL	60643-4734	04/16/2015	07/01/2015	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07411	3200 VOLLMER ROAD	OLYMPIA FIELDS	IL	60461-1122	04/16/2015	07/01/2015	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09326	9554 E LINCOLN HWY	FRANKFORT	IL	60423	04/16/2015	07/01/2015	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 13106	11801 S. AVENUE O	CHICAGO	IL	60617	04/16/2015	07/01/2015	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #15305	912 W BELMONT AVE	CHICAGO	IL	60657	07/13/2017	10/01/2017	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	07/13/2017	10/01/2017	08/09/2019	08/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09924	390 EAST 162ND STREET	SOUTH HOLLAND	IL	60473-0241	09/03/2021	09/08/2021	11/18/2022	11/18/2022
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	01/13/2014	04/01/2014	07/01/2015	07/14/2015
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	07/07/2021	10/01/2021	11/18/2022	11/18/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/07/2021	10/01/2021	06/29/2021	07/13/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/07/2021	10/01/2021	11/18/2022	11/18/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/07/2021	10/01/2021	11/08/2021	01/12/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/07/2021	10/01/2021	11/08/2021	01/12/2022

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140191A	Child	DSH	INGALLS MEMORIAL HOSPITAL	Ingalls Family Care Center - Flossmoor -- Infusion Center	19550 Governors Hwy	Flossmoor	IL	Active
DSH140191B	Child	DSH	INGALLS MEMORIAL HOSPITAL	Ingalls Family Care Center - Calumet City -- Infusion Center	1600 Torrence Ave	Calumet City	IL	Active
DSH140191C	Child	DSH	INGALLS MEMORIAL HOSPITAL	Ingalls Family Care Center - Tinley Park -- Infusion Center	6701 W. 159th Street	Tinley Park	IL	Active
DSH140191D	Child	DSH	INGALLS MEMORIAL HOSPITAL	Ingalls Family Care Center -- Tinley Park -- Urgent Aid	6701 W. 159th St.	Tinley Park	IL	Active
DSH140191E	Child	DSH	INGALLS MEMORIAL HOSPITAL	Ingalls Family Care Center -- Flossmoor -- Urgent Aid	19550 Governors Highway	Flossmoor	IL	Active
DSH140191F	Child	DSH	INGALLS MEMORIAL HOSPITAL	Ingalls Family Care Center -- Calumet City -- Urgent Aid	1600 Torrence Ave.	Calumet City	IL	Active
DSH140191G	Child	DSH	INGALLS MEMORIAL HOSPITAL	INGALLS FAMILY CARE CENTER - Tinley Park Ambulatory Infusion	6701 159TH ST	TINLEY PARK	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Delete	Change Request	1679250336 (IL)		4/9/2025 12:45 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841387388	4/9/2025 12:45 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/9/2025 12:45 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598756686	4/9/2025 12:45 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/9/2025 12:45 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598756686	4/9/2025 12:45 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/9/2025 12:45 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598756686	4/9/2025 12:45 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	4/9/2025 12:45 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300020333 (IN)		1/15/2025 11:37 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	362170866-001 (IL)		1/15/2025 11:37 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	362170866-002 (IL)		1/15/2025 11:37 AM
Details	Last Recertification Date	Update	Recertification	8/31/2023 11:12:41 AM	8/29/2024 10:20:58 AM	8/29/2024 10:20 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1598756686 (CA)		7/12/2024 2:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (CA)		7/12/2024 2:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (WI)		7/12/2024 2:35 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (AL)		7/12/2024 2:35 PM
Contacts	Primary Contact	Update	Profile Change Request	SAMEK, TOM ASSISTANT GENERAL COUNSEL Ingalls Memorial Hospital 7089156368	SAMEK, TOM ASSISTANT GENERAL COUNSEL Ingalls Memorial Hospital 7737024405	6/11/2024 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1598756686	1/10/2024 8:59 AM
Medicaid Billing	NPI: State	Insert	Change Request		AL	1/10/2024 8:59 AM
Contacts	Primary Contact	Update	Change Request	Samek, Tom Associate General Counsel Ingalls Memorial Hospital 7737024405	SAMEK, TOM ASSISTANT GENERAL COUNSEL Ingalls Memorial Hospital 7089156368	1/10/2024 8:59 AM
Contacts	Primary Contact	Update	Change Request	SAMEK, TOM ASSISTANT GENERAL COUNSEL Ingalls Memorial Hospital 7089156368	Samek, Tom Associate General Counsel Ingalls Memorial Hospital 7737024405	11/3/2023 8:00 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000108083A (GA)		10/12/2023 11:40 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (GA)		10/12/2023 11:40 AM
Contacts	Authorizing Official	Update	AO Change Request	Haggerty, Sara Interim CFO CHHD Ingalls Memorial Hospital 7089156110	Scarpelli, Denise Vice President, Chief Pharmacy Officer The University of Chicago Medical Center 7738345601	9/29/2023 3:09 PM
Details	Last Recertification Date	Update	Recertification	9/19/2022 10:47:20 AM	8/31/2023 11:12:41 AM	8/31/2023 11:12 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1679250336	7/24/2023 1:03 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	7/24/2023 1:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (MI)		4/14/2023 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598756686	4/14/2023 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/14/2023 2:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598756686	4/14/2023 2:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	4/14/2023 2:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/12/2023 2:38 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1598756686	1/12/2023 2:38 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	1/12/2023 2:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598756686	1/12/2023 2:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	1/12/2023 2:38 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 3:40:25 PM	9/19/2022 10:47:20 AM	9/19/2022 10:47 AM
Contacts	Authorizing Official	Update	AO Change Request	Saegesser, Douglas S CFO Ingalls Memorial Hospital 7089156110	Haggerty, Sara Interim CFO CHHD Ingalls Memorial Hospital 7089156110	10/4/2021 9:20 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 8:25:21 AM	9/7/2021 3:40:25 PM	9/7/2021 3:40 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1598756686 (CT)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	092864000 (FL)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	164640 (AZ)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1598756686 (IA)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1598756686 (MN)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1468928 (ND)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0211407 (OH)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	q026614 (TN)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2042044 (WA)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1598756686 (CA)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	80488600 (WI)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (CA)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (WI)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (OH)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (FL)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (ND)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (CT)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (IA)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (MN)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (AZ)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (WA)		1/18/2021 11:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1598756686 (TN)		1/18/2021 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1598756686 (ME)		9/11/2020 8:25 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	001287077 (NV)		9/11/2020 8:25 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	071920501 (TX)		9/11/2020 8:25 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1598756686 (WI)		9/11/2020 8:25 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	362170866401 (IL)		9/11/2020 8:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 8:25 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/11/2020 8:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 8:25 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		80488600	9/11/2020 8:25 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1932296472 ( )		9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1841387388 ( )		9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1821185364 ( )		9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1679198014 ( )		9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1598756686 ( )		9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841387388	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		ND	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1598756686	9/11/2020 8:25 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/11/2020 8:25 AM
Details	Last Recertification Date	Update	Recertification	9/15/2019 7:48:51 AM	9/11/2020 8:25:21 AM	9/11/2020 8:25 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1679198014	7/6/2020 2:33 PM
Contacts	Authorizing Official	Update	AO Change Request	Kaufman, Phillip VP of Finance Ingalls 7089156110	Saegesser, Douglas S CFO Ingalls Memorial Hospital 7089156110	4/14/2020 11:51 AM
Addresses	Billing Address	Insert	Change Request		Ingalls Memorial Hospital 150 Harvester Drive Suite 300 Burr Ridge, IL 60527	1/15/2020 1:23 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1043307580 (IL)		1/15/2020 1:23 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1023105566 (IL)		1/15/2020 1:23 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	36217086401	362170866401	1/15/2020 1:23 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1598756686	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		092864000	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		164640	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000108083A	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300020333	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1598756686	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1598756686	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1598756686	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		001287077	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NV	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1468928	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ND	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0211407	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		q026614	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		071920501	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2042044	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1598756686	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1043307580	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1023105566	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		36217086401	9/15/2019 7:48 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/15/2019 7:48 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932296472	9/15/2019 7:48 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1841387388	9/15/2019 7:48 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1821185364	9/15/2019 7:48 AM
Details	Last Recertification Date	Update	Recertification	9/10/2018 4:48:01 PM	9/15/2019 7:48:51 AM	9/15/2019 7:48 AM
Contacts	Authorizing Official	Update	AO Change Request	lawrence, michael a chief financial officer Ingalls Memorial Hospital 7089156110	Kaufman, Phillip VP of Finance Ingalls 7089156110	9/13/2019 6:38 AM
Contacts	Authorizing Official	Update	AO Change Request	Goble, Jonathan Ray President Ingalls Memorial Hospital 7089155500	lawrence, michael a chief financial officer Ingalls Memorial Hospital 7089156110	6/4/2019 2:18 PM
Details	Last Recertification Date	Update	Recertification	12/6/2017 8:28:48 AM	9/10/2018 4:48:01 PM	9/10/2018 4:48 PM
Contacts	Authorizing Official	Update	Change Request	JOHNSON, KURT E. CEO Ingalls Memorial Hospital 7089156101	Goble, Jonathan Ray President Ingalls Memorial Hospital 7089155500	7/11/2018 12:00 PM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	12/6/2017 8:28:48 AM	12/6/2017 8:28 AM
Contacts	Authorizing Official	Update		JOHNSON, KURT E. CEO 7089156101	JOHNSON, KURT E. CEO Ingalls Memorial Hospital 7089156101	10/13/2017 11:51 AM
Contacts	Primary Contact	Update		SAMEK, TOM ASSISTANT GENERAL COUNSEL 7089156368	SAMEK, TOM ASSISTANT GENERAL COUNSEL Ingalls Memorial Hospital 7089156368	9/25/2017 3:37 PM
Contacts	Authorizing Official	Insert			JOHNSON, KURT E. CEO 7089156101	7/17/2017 11:48 AM
Addresses	Main Address	Insert			ONE INGALLS DRIVE HARVEY, IL 60426	2/13/2017 2:30 PM
Contacts	Primary Contact	Update		Jacoby, Diane General Counsel 7089156139	SAMEK, TOM ASSISTANT GENERAL COUNSEL 7089156368	2/13/2017 2:30 PM
Contacts	Primary Contact	Insert			Jacoby, Diane General Counsel 7089156139	9/6/2016 8:54 PM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 8:54 PM
Medicaid Billing	NPI: Number	Insert			1598756686	8/31/2015 10:36 AM
Details	Last Recertification Date	Update		8/8/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 3:40 PM
Details	Last Recertification Date	Update		9/13/2013 12:00:00 AM	8/8/2014 12:00:00 AM	8/8/2014 9:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/13/2013 11:41 AM
Medicaid Billing	Medicaid: Number	Insert			362170866-001	9/13/2013 11:41 AM
Medicaid Billing	Medicaid: State	Insert			IL	9/13/2013 11:41 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/13/2013 11:41 AM
Medicaid Billing	Medicaid: Number	Insert			362170866-002	9/13/2013 11:41 AM
Medicaid Billing	Medicaid: State	Insert			IL	9/13/2013 11:41 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/13/2013 12:00:00 AM	9/13/2013 11:41 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/16/2012 7:44 AM
Details	Last Recertification Date	Insert				3/23/2007 9:45 AM
Details	Grant Number	Insert				3/23/2007 9:45 AM
Details	340B ID	Insert			DSH140191	3/23/2007 9:45 AM
Details	Is Authorizing Official EHB Data	Insert				3/23/2007 9:45 AM
Dates	Last Date That 340B Drugs Purchased	Insert				3/23/2007 9:45 AM
Details	Medicare Provider Number	Insert			140191	3/23/2007 9:45 AM
Details	Entity Name	Insert			INGALLS MEMORIAL HOSPITAL	3/23/2007 9:45 AM
Details	Program Code	Insert			DSH	3/23/2007 9:45 AM
Details	Entity Subname	Insert				3/23/2007 9:45 AM
Dates	Participating Approval Date	Insert			9/22/2005 12:00:00 AM	3/23/2007 9:45 AM
Details	State	Insert			Active	3/23/2007 9:45 AM
Dates	Registration Date	Insert			9/22/2005 12:00:00 AM	3/23/2007 9:45 AM
Dates	Signed By Date	Insert			5/26/2005 12:00:00 AM	3/23/2007 9:45 AM
Dates	Start Date	Insert			9/22/2005 12:00:00 AM	3/23/2007 9:45 AM
Terminations	Termination Comments	Insert				3/23/2007 9:45 AM
Terminations	Termination Date	Insert				3/23/2007 9:45 AM
Terminations	Termination Effective Date	Insert				3/23/2007 9:45 AM
Terminations	Termination Reason	Insert				3/23/2007 9:45 AM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

Parent/Child

History