Covered Entity Details

DSH230070 COVENANT MEDICAL CENTER (Active) - information as of 5/25/2025 1:19:48 AM

Main Details

Name

COVENANT MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH230070

Medicare Provider Number

230070

Additional Details

Current Program Status

Active

Registration Date

10/18/2007

Participating Start Date

4/1/2004

Participating Approval Date

10/18/2007

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Covenant Medical Center
KEVIN S. ALBOSTA, CFO
(989) 583-2769

Primary Contact

Covenant Medical Center
Aaron Feinauer, Director of Pharmacy
(989) 583-4788

Addresses

Street Address

1447 N HARRISON STREET
SAGINAW, MI 48602

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
MI		1588656946,1619412376

Shipping Addresses

Shipping Address 1

MACKINAW INFUSION PHARMACY
5400 MACKINAW RD
SAGINAW, MI 48604

Shipping Address 2

COOPER INPATIENT PHARMACY
700 COOPER AVE
SAGINAW, MI 48602

Shipping Address 3

HARRISON INPATIENT PHARMACY
1447 N HARRISON ST
SAGINAW, MI 48602

Shipping Address 4

COOPER OUTPATIENT PHARMACY
700 COOPER
SAGINAW, MI 48602

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	BRADY DRUGS	7835 GRATIOT RD		SAGINAW	MI	48609-5020	07/15/2013	10/01/2013	02/28/2018	03/08/2018
Contract Detail	BRIDGEPORT HEALTH-MART PHARMACY	6224 DIXIE HWY		BRIDGEPORT	MI	48722-9513	04/16/2014	07/01/2014	10/15/2018	10/16/2018
Contract Detail	BRIDGEPORT PHARMACY INC		6224 DIXIE HIGHWAY	BRIDGEPORT	MI	48722	07/15/2013	10/01/2013	05/02/2016	07/24/2017
Contract Detail	COVENANT HEALTHCARE	700 COOPER		SAGINAW	MI	48602	10/14/2014	01/01/2015	03/31/2024	04/01/2024
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/12/2021	01/01/2022	04/13/2022	05/26/2022
Contract Detail	FBM DRUG COMPANY	DBA BIRCH RUN DRUGS	8501 MAIN ST	BIRCH RUN	MI	48415	07/15/2013	10/01/2013	05/02/2016	07/24/2017
Contract Detail	FBM DRUG COMPANY		DBA SATOW DRUG STORE 308 S MAIN ST	FRANKENMUTH	MI	48734	07/15/2013	10/01/2013	05/02/2016	07/24/2017
Contract Detail	KROGER DBA: KESSEL #410		3860 DIXIE HIGHWAY	SAGINAW	MI	48601	07/17/2013	10/01/2013	04/23/2016	07/24/2017
Contract Detail	KROGER DBA: KESSEL #411	5025 GRATIOT ROAD		SAGINAW	MI	48638	07/17/2013	10/01/2013	11/19/2017	12/12/2017
Contract Detail	MEIJER DISTRIBUTION INC #90	2721 WALKER AVE NW		GRAND RAPIDS	MI	49544	04/15/2013	07/01/2013		07/24/2017
Contract Detail	MEIJER INC #108	7300 EASTMAN ROAD		MIDLAND	MI	48642	04/15/2013	07/01/2013		07/24/2017
Contract Detail	MEIJER INC #187	595 N. PINE		BAY CITY	MI	48708	04/15/2013	07/01/2013		07/24/2017
Contract Detail	MEIJER INC #213	9515 BIRCH RUN ROAD		BIRCH RUN	MI	48415-9613	04/15/2013	07/01/2013		07/24/2017
Contract Detail	MEIJER INC #42	8400 GRATIOT ROAD		SAGINAW	MI	48609	04/15/2013	07/01/2013		07/24/2017
Contract Detail	MEIJER INC #43	3360 TITTABAWASSEE ROAD		SAGINAW	MI	48604	04/15/2013	07/01/2013		07/24/2017
Contract Detail	MEIJER INC #48	2980 E WILDER ROAD		BAY CITY	MI	48706	04/15/2013	07/01/2013		07/24/2017
Contract Detail	MEIJER PHARMACY #464	41255 COCA COLA DR.		BELLEVILLE	MI	48111-1827	10/10/2016	01/01/2017		07/24/2017
Contract Detail	MEIJER STORES LIMITED PARTNERSHIP	D/B/A MEIJER PHARMACY #463	1515 PROFIT DR.	FORT WAYNE	IN	46808	04/15/2013	07/01/2013		07/24/2017
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/11/2022	04/13/2022		04/19/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/12/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/12/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	10/12/2021	01/01/2022		01/01/2022
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	10/12/2021	01/01/2022		01/01/2022
Contract Detail	PRINCING'S PHARMACY	333 S MICHIGAN AVE		SAGINAW	MI	48602	07/17/2013	10/01/2013	04/29/2016	07/24/2017
Contract Detail	SUPERX DRUG CORPORATION	DBA KROGER CO #635	2910 CENTER AVENUE	ESSEXVILLE	MI	48732	07/17/2013	10/01/2013	08/09/2019	09/05/2019
Contract Detail	THE KROGER CO OF MICHIGAN	435 N MAIN STREET		FRANKENMUTH	MI	48734	07/17/2013	10/01/2013	01/17/2025	01/27/2025
Contract Detail	THE KROGER PHARMACY 738	4672 STATE STREET		SAGINAW	MI	48603-3805	07/17/2013	10/01/2013	01/17/2025	01/27/2025
Contract Detail	VISITING NURSE ASSOCIATION OF SAGINAW	COVENANT VISITING NURSE ASSOCIATION	515 N MICHIGAN AVE	SAGINAW	MI	48602	04/16/2013	07/01/2013		07/24/2017
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/13/2017	10/01/2017		07/24/2017
Contract Detail	WAL-MART PHARMACY 10-1798	1121 E CARO RD		CARO	MI	48723	01/16/2014	04/01/2014		07/24/2017
Contract Detail	WAL-MART PHARMACY 10-2644	5825 BROCKWAY ROAD		SAGINAW	MI	48638	01/16/2014	04/01/2014		07/24/2017
Contract Detail	WAL-MART PHARMACY 10-5097	5650 BAY RD		SAGINAW	MI	48604	01/16/2014	04/01/2014		07/24/2017
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/13/2017	10/01/2017		07/24/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05097	4989 STATE ST	SAGINAW	MI	48603	07/15/2013	10/01/2013		07/24/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05167	416 S. EUCLID AVE.	BAY CITY	MI	48706	07/15/2013	10/01/2013		07/24/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05371	2990 BAY ROAD	SAGINAW	MI	48603	07/15/2013	10/01/2013		07/24/2017
Contract Detail	WALGREEN CO.	WALGREENS #21328	3730 DIXIE HWY	SAGINAW	MI	48601	07/15/2013	10/01/2013		07/24/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #21378	1841 N MICHIGAN AVE	SAGINAW	MI	48602	07/15/2013	10/01/2013		07/24/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06559	931 S SAGINAW RD	MIDLAND	MI	48640-4602	07/15/2013	10/01/2013		07/24/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09079	1615 N SAGINAW RD	MIDLAND	MI	48640-7237	07/15/2013	10/01/2013		07/24/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09450	830 N VAN DYKE RD	BAD AXE	MI	48413-9016	07/15/2013	10/01/2013		07/24/2017
Contract Detail	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	10/12/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/15/2013	10/01/2013	07/27/2015	07/24/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/13/2021	07/01/2021		07/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/13/2021	07/01/2021		07/01/2021
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/16/2023	04/01/2023		04/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/09/2023	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH230070A	Child	DSH	COVENANT MEDICAL CENTER	COVENANT HEALTHCARE - ANESTHESIA	700 COOPER AVE	SAGINAW	MI	Active
DSH230070AA	Child	DSH	COVENANT MEDICAL CENTER	OCCUPATIONAL THERAPY - BAY CITY OT	2919 WILDER RD	BAY CITY	MI	Active
DSH230070AB	Child	DSH	COVENANT MEDICAL CENTER	OCCUPATIONAL THERAPY - MACKINAW OT	5400 MACKINAW RD	SAGINAW	MI	Active
DSH230070AC	Child	DSH	COVENANT MEDICAL CENTER	OCCUPATIONAL THERAPY - NEURO OT COOPER	700 COOPER AVE	SAGINAW	MI	Active
DSH230070AD	Child	DSH	COVENANT MEDICAL CENTER	OCCUPATIONAL THERAPY - ORTHO OT COOPER	700 COOPER AVE	SAGINAW	MI	Active
DSH230070AE	Child	DSH	COVENANT MEDICAL CENTER	OCCUPATIONAL THERAPY - OT FRANKENMUTH	600 N MAIN ST	FRANKENMUTH	MI	Active
DSH230070AF	Child	DSH	COVENANT MEDICAL CENTER	PHYSICAL THERAPY - BAY CITY PT	2919 WILDER RD	BAY CITY	MI	Active
DSH230070AG	Child	DSH	COVENANT MEDICAL CENTER	PHYSICAL THERAPY - HEMLOCK PT	16440 GRATIOT RD	HEMLOCK	MI	Active
DSH230070AH	Child	DSH	COVENANT MEDICAL CENTER	PHYSICAL THERAPY - MACKINAW PT	5400 MACKINAW RD	SAGINAW	MI	Active
DSH230070AJ	Child	DSH	COVENANT MEDICAL CENTER	PHYSICAL THERAPY - NEURO PT COOPER	700 COOPER AVE	SAGINAW	MI	Active
DSH230070AK	Child	DSH	COVENANT MEDICAL CENTER	PHYSICAL THERAPY - ORTHO PT COOPER	700 COOPER AVE	SAGINAW	MI	Active
DSH230070AL	Child	DSH	COVENANT MEDICAL CENTER	PHYSICAL THERAPY - PT FRANKENMUTH	600 N MAIN ST	FRANKENMUTH	MI	Active
DSH230070AM	Child	DSH	COVENANT MEDICAL CENTER	PHYSICAL THERAPY - PT GRATIOT	5483 GRATIOT RD	SAGINAW	MI	Active
DSH230070AN	Child	DSH	COVENANT MEDICAL CENTER	SPEECH PATHOLOGY - OUTPATIENT SPEECH THERAPY	700 COOPER AVE	SAGINAW	MI	Active
DSH230070AP	Child	DSH	COVENANT MEDICAL CENTER	LABORATORY - BAY CITY CAMPUS	2919 WILDER RD	BAY CITY	MI	Active
DSH230070AQ	Child	DSH	COVENANT MEDICAL CENTER	LABORATORY - GRATIOT CAMPUS	16440 GRATIOT RD	HEMLOCK	MI	Active
DSH230070AR	Child	DSH	COVENANT MEDICAL CENTER	LABORATORY - STATE STREET CAMPUS	5570 STATE ST	SAGINAW	MI	Active
DSH230070AS	Child	DSH	COVENANT MEDICAL CENTER	LABORATORY - FRANKENMUTH CAMPUS	600 N MAIN ST	FRANKENMUTH	MI	Active
DSH230070AT	Child	DSH	COVENANT MEDICAL CENTER	LABORATORY - IRVING CAMPUS	600 IRVING AVE	SAGINAW	MI	Active
DSH230070AU	Child	DSH	COVENANT MEDICAL CENTER	LABORATORY - MACKINAW CAMPUS	5400 MACKINAW RD	SAGINAW	MI	Active
DSH230070AV	Child	DSH	COVENANT MEDICAL CENTER	RADIOLOGY ULTRASOUND - STATE STREET US	5570 STATE ST	SAGINAW	MI	Active
DSH230070AW	Child	DSH	COVENANT MEDICAL CENTER	NUCLEAR MEDICINE - MACKINAW CAMPUS	5400 MACKINAW RD	SAGINAW	MI	Active
DSH230070AX	Child	DSH	COVENANT MEDICAL CENTER	RADIOLOGY ULTRASOUND - MACKINAW CAMPUS	5400 MACKINAW RD	SAGINAW	MI	Active
DSH230070AY	Child	DSH	COVENANT MEDICAL CENTER	DIAGNOSTIC RADIOLOGY - MACKINAW CAMPUS	5400 MACKINAW RD	SAGINAW	MI	Active
DSH230070AZ	Child	DSH	COVENANT MEDICAL CENTER	RADIOLOGY ULTRASOUND - FRANKENMUTH	600 N MAIN ST	FRANKENMUTH	MI	Active
DSH230070B	Child	DSH	COVENANT MEDICAL CENTER	COVENANT HEALTHCARE MACKINAW	5400 MACKINAW	SAGINAW	MI	Terminated
DSH230070BA	Child	DSH	COVENANT MEDICAL CENTER	NUCLEAR MEDICINE - COOPER E NM	900 COOPER AVE	SAGINAW	MI	Active
DSH230070BB	Child	DSH	COVENANT MEDICAL CENTER	RADIOLOGY ULTRASOUND - COOPER CAMPUS	700 COOPER AVE	SAGINAW	MI	Active
DSH230070BC	Child	DSH	COVENANT MEDICAL CENTER	BREAST HEALTH DIAGNOSTICS - STATE STREET BREAST HEALTH	5570 STATE ST	SAGINAW	MI	Active
DSH230070BD	Child	DSH	COVENANT MEDICAL CENTER	BREAST HEALTH DIAGNOSTICS - FRANKENMUTH BREAST HEALTH	600 N MAIN ST	FRANKENMUTH	MI	Active
DSH230070BE	Child	DSH	COVENANT MEDICAL CENTER	DIAGNOSTIC RADIOLOGY - COOPER E DIAGNOSTIC IMAGING	900 COOPER AVE	Saginaw	MI	Active
DSH230070E	Child	DSH	COVENANT MEDICAL CENTER	Covenant Medical Center Emergency	900 Cooper	Saginaw	MI	Active
DSH230070F	Child	DSH	COVENANT MEDICAL CENTER	CANCER CARE AND INFUSION THERAPY	5400 MACKINAW RD	SAGINAW	MI	Active
DSH230070G	Child	DSH	COVENANT MEDICAL CENTER	COVENANT 900 COOPER / ENDOSCOPY	900 COOPER AVE	SAGINAW	MI	Active
DSH230070H	Child	DSH	COVENANT MEDICAL CENTER	COVENANT 900 COOPER / CARDIAC TESTING	900 COOPER AVE	SAGINAW	MI	Active
DSH230070J	Child	DSH	COVENANT MEDICAL CENTER	COVENANT 900 COOPER / CARDIAC RECOVERY	900 COOPER AVE	SAGINAW	MI	Active
DSH230070K	Child	DSH	COVENANT MEDICAL CENTER	COVENANT 700 COOPER / CARDIAC CATH LAB/EP LAB	700 COOPER AVE	SAGINAW	MI	Active
DSH230070L	Child	DSH	COVENANT MEDICAL CENTER	COVENANT 700 COOPER AVE / INTERVENTIONAL RADIOLOGY	700 COOPER AVE	SAGINAW	MI	Active
DSH230070M	Child	DSH	COVENANT MEDICAL CENTER	COVENANT 700 COOPER / COOPER POHA/PACU/AMBU	700 COOPER AVE	SAGINAW	MI	Active
DSH230070N	Child	DSH	COVENANT MEDICAL CENTER	700 COOPER BUILDING / COOPER OR	700 COOPER AVE	SAGINAW	MI	Active
DSH230070P	Child	DSH	COVENANT MEDICAL CENTER	COVENANT 900 COOPER / CLINICAL DECISION UNIT	900 COOPER AVE	SAGINAW	MI	Active
DSH230070Q	Child	DSH	COVENANT MEDICAL CENTER	COVENANT RADIOLOGY - NUCLEAR MEDICINE	700 COOPER AVE	SAGINAW	MI	Active
DSH230070R	Child	DSH	COVENANT MEDICAL CENTER	COVENANT RESPIRATORY THERAPY	700 COOPER AVE	SAGINAW	MI	Active
DSH230070S	Child	DSH	COVENANT MEDICAL CENTER	Radiology Diagnostic - 72020 Breast Health Center	5400 Mackinaw Rd	Saginaw	MI	Active
DSH230070T	Child	DSH	COVENANT MEDICAL CENTER	Oncology - 79095 Covenant Radiation Center	4141 Tittabawassee Rd	Saginaw	MI	Active
DSH230070U	Child	DSH	COVENANT MEDICAL CENTER	CARDIAC REHAB MACKINAW - CARDIAC REHAB MACKINAW	5400 MACKINAW RD	SAGINAW	MI	Active
DSH230070V	Child	DSH	COVENANT MEDICAL CENTER	CLINIC - WOUND CARE	900 COOPER	SAGINAW	MI	Active
DSH230070W	Child	DSH	COVENANT MEDICAL CENTER	DIAGNOSTIC RADIOLOGY - BONE DENSITY	5570 STATE ST	SAGINAW	MI	Active
DSH230070X	Child	DSH	COVENANT MEDICAL CENTER	DIAGNOSTIC RADIOLOGY - PET SCAN	600 IRVING AVE	SAGINAW	MI	Active
DSH230070Y	Child	DSH	COVENANT MEDICAL CENTER	ELECTROCARDIOLOGY - NEURODIAGNOSTICS	700 COOPER AVE	SAGINAW	MI	Active
DSH230070Z	Child	DSH	COVENANT MEDICAL CENTER	MARLETTE ONCOLOGY - INFUSION AND RADIATION CENTER	2780 MAIN ST	MARLETTE	MI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619412376	3/4/2025 9:47 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MI	3/4/2025 9:47 AM
Addresses	Shipping Address	Update	Change Request	COOPER INPATIENT PHARMACY 700 COOPER AVE SUITE 2MA071 SAGINAW, MI 48602	COOPER INPATIENT PHARMACY 700 COOPER AVE SAGINAW, MI 48602	12/17/2024 8:07 AM
Addresses	Shipping Address	Delete	Group Change Request	MARLETTE INFUSION PHARMACY 2780 MAIN ST MARLETTE, MI 48453		10/15/2024 9:08 AM
Details	Last Recertification Date	Update	Recertification	9/3/2023 10:31:18 PM	8/13/2024 7:20:31 AM	8/13/2024 7:20 AM
Contacts	Primary Contact	Update	Change Request	Feinauer, Aaron Director of Pharmacy Covenant Medical Center 9895834077	Feinauer, Aaron Director of Pharmacy Covenant Medical Center 9895834788	8/5/2024 12:16 PM
Contacts	Primary Contact	Update	Group Change Request	WERNETTE, TERRENCE DIRECTOR OF PHARMACY Covenant HealthCare 9895834075	Feinauer, Aaron Director of Pharmacy Covenant Medical Center 9895834077	6/3/2024 4:17 PM
Addresses	Shipping Address	Insert	Change Request		MARLETTE INFUSION PHARMACY 2780 MAIN ST MARLETTE, MI 48453	2/6/2024 2:39 PM
Addresses	Shipping Address	Insert	Change Request		COOPER OUTPATIENT PHARMACY 700 COOPER SAGINAW, MI 48602	2/6/2024 2:39 PM
Addresses	Shipping Address	Update	Change Request	MACKINAW INFUSION PHARMACY 5400 MACKINAW RD SUITE 3300 SAGINAW, MI 48604	MACKINAW INFUSION PHARMACY 5400 MACKINAW RD SAGINAW, MI 48604	12/22/2023 8:22 AM
Addresses	Shipping Address	Update	Change Request	MACKINAW INFUSION PHARMACY 5400 MACKINAW AVE SUITE 3300 SAGINAW, MI 48604	MACKINAW INFUSION PHARMACY 5400 MACKINAW RD SUITE 3300 SAGINAW, MI 48604	12/18/2023 10:58 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 10:43:39 AM	9/3/2023 10:31:18 PM	9/3/2023 10:31 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 8:44:57 AM	9/7/2022 10:43:39 AM	9/7/2022 10:43 AM
Addresses	Shipping Address	Insert	Change Request		HARRISON INPATIENT PHARMACY 1447 N HARRISON ST SAGINAW, MI 48602	5/31/2022 9:31 AM
Details	Last Recertification Date	Update	Recertification	8/25/2020 8:13:56 AM	8/24/2021 8:44:57 AM	8/24/2021 8:44 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1588656946	8/25/2020 8:13 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/25/2020 8:13 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1588656946 ( )		8/25/2020 8:13 AM
Details	Last Recertification Date	Update	Recertification	9/10/2019 11:27:21 AM	8/25/2020 8:13:56 AM	8/25/2020 8:13 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 12:48:06 PM	9/10/2019 11:27:21 AM	9/10/2019 11:27 AM
Details	Last Recertification Date	Update	Recertification	12/1/2017 3:15:18 PM	8/22/2018 12:48:06 PM	8/22/2018 12:48 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1588656946	12/5/2017 9:12 AM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	12/1/2017 3:15:18 PM	12/1/2017 3:15 PM
Contacts	Authorizing Official	Update		ALBOSTA, KEVIN S. CFO 9895832769	ALBOSTA, KEVIN S. CFO Covenant Medical Center 9895832769	10/24/2017 2:31 PM
Contacts	Primary Contact	Update		WERNETTE, TERRENCE DIRECTOR OF PHARMACY 9895834075	WERNETTE, TERRENCE DIRECTOR OF PHARMACY Covenant HealthCare 9895834075	10/22/2017 2:34 PM
Contacts	Authorizing Official	Insert			ALBOSTA, KEVIN S. CFO 9895832769	7/24/2017 6:14 PM
Contacts	Primary Contact	Insert			WERNETTE, TERRENCE DIRECTOR OF PHARMACY 9895834075	7/24/2017 6:14 PM
Addresses	Main Address	Insert			1447 N HARRISON STREET SAGINAW, MI 48602	7/24/2017 6:14 PM
Addresses	Shipping Address	Insert			MACKINAW INFUSION PHARMACY 5400 MACKINAW AVE SUITE 3300 SAGINAW, MI 48604	7/24/2017 6:14 PM
Addresses	Shipping Address	Insert			COOPER INPATIENT PHARMACY 700 COOPER AVE SUITE 2MA071 SAGINAW, MI 48602	7/24/2017 6:14 PM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 1:22 PM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 10:32 AM
Dates	Participating Approval Date	Update		10/18/2007 7:04:52 AM	10/18/2007 12:00:00 AM	7/17/2015 1:44 PM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 2:24 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 10:12 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/14/2012 10:13 AM
Details	Last Recertification Date	Insert				10/18/2007 7:07 AM
Details	Grant Number	Insert				10/18/2007 7:07 AM
Details	340B ID	Insert			DSH230070	10/18/2007 7:07 AM
Details	Is Authorizing Official EHB Data	Insert				10/18/2007 7:07 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/18/2007 7:07 AM
Details	Medicare Provider Number	Insert			230070	10/18/2007 7:07 AM
Details	Entity Name	Insert			COVENANT MEDICAL CENTER	10/18/2007 7:07 AM
Details	Program Code	Insert			DSH	10/18/2007 7:07 AM
Details	Entity Subname	Insert				10/18/2007 7:07 AM
Dates	Participating Approval Date	Insert			10/18/2007 7:04:52 AM	10/18/2007 7:07 AM
Details	State	Insert			Active	10/18/2007 7:07 AM
Dates	Registration Date	Insert			10/18/2007 12:00:00 AM	10/18/2007 7:07 AM
Dates	Signed By Date	Insert				10/18/2007 7:07 AM
Dates	Start Date	Insert			4/1/2004 12:00:00 AM	10/18/2007 7:07 AM
Terminations	Termination Comments	Insert				10/18/2007 7:07 AM
Terminations	Termination Date	Insert				10/18/2007 7:07 AM
Terminations	Termination Effective Date	Insert				10/18/2007 7:07 AM
Terminations	Termination Reason	Insert				10/18/2007 7:07 AM