Covered Entity Details

DSH140180 Presence Saints Mary and Elizabeth Medical Center (Terminated) - information as of 6/16/2025 5:49:19 AM

Main Details

Name

Presence Saints Mary and Elizabeth Medical Center

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH140180

Medicare Provider Number

140180

Additional Details

Current Program Status

Terminated

Registration Date

4/21/2008

Participating Start Date

7/1/2003

Participating Approval Date

4/21/2008

Last Recertification Date

8/16/2024

Termination Date
Termination Reason

4/1/2025
For-Profit conversion

Contacts

Authorizing Official

Ascension Saint Mary & Elizabeth MEdical Center
Eric Zornow, CFO
(312) 770-2105

Primary Contact

Ascension
Rick Fischer, 340B Program Director
(630) 309-7828

Addresses

Street Address

2233 WEST DIVISION STREET
CHICAGO, IL 60622

Billing Address

Ascension Health Ministry Service Center
PO Box 33902
Indianapolis, IN 46203

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	36-2235165	1922177229

Shipping Addresses

Shipping Address 1

Ascension RX
7701 Metropolis Drive
200C
Austin, TX 78744

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	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/20/2020	04/01/2020	03/04/2024	03/04/2024
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/17/2023	10/01/2023	03/04/2024	03/04/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/20/2020	04/01/2020	05/31/2023	06/15/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/03/2022	04/01/2022	03/04/2024	03/04/2024
Contract Detail	ADVENTIST MIDWEST HEALTH	DBA UCHICAGO MEDICINE ADVENTHEALTH HINSD	120 N OAK ST	HINSDALE	IL	60521	10/01/2018	01/01/2019	04/29/2022	04/29/2022
Contract Detail	AFFILIATED HEALTH SERVICES, INC.	DBA ASCENSION RX 1303	30055 NORTHWESTERN HWY STE 225	FARMINGTON HILLS	MI	48334	10/17/2019	01/01/2020	01/26/2022	02/12/2022
Contract Detail	ASCENSION PHARMACY SERVICES, LLC	DBA ASCENSION RX 1303	30055 NORTHWESTERN HWY STE 225	FARMINGTON HILLS	MI	48334	01/14/2022	01/26/2022	04/01/2025	04/01/2025
Contract Detail	ASCENSION RX 1001	ASCENSION PHARMACY SERVICES, LLC.	7701 METROPOLIS DR STE 200B	AUSTIN	TX	78744-3125	04/12/2022	07/01/2022	04/01/2025	04/01/2025
Contract Detail	ASCENSION RX 3001	7701 METROPOLIS DR STE 200C		AUSTIN	TX	78744-3125	07/22/2021	10/01/2021	04/29/2022	09/28/2022
Contract Detail	AVELLA OF COLUMBUS	4830 KNIGHTSBRIDGE BLVD STE C		COLUMBUS	OH	43214-2300	01/18/2017	04/01/2017	04/01/2020	05/07/2020
Contract Detail	AVELLA OF DEER VALLEY	23620 N 20TH DR #12		PHOENIX	AZ	85085-0621	01/18/2017	04/01/2017	04/01/2020	05/07/2020
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	01/18/2017	04/01/2017	07/15/2020	07/27/2020
Contract Detail	AVELLA OF ORLANDO	100 TECHNOLOGY PARK STE 155		LAKE MARY	FL	32746-6205	01/15/2018	04/01/2018	04/01/2020	05/07/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01298	1372 N MILWAUKEE AVE	CHICAGO	IL	60622	10/15/2015	01/01/2016	04/01/2025	04/01/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02877	2440 W NORTH AVE	CHICAGO	IL	60647	10/15/2015	01/01/2016	04/01/2025	04/01/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03698	3201 N. BROADWAY ST.	CHICAGO	IL	60657	10/15/2015	01/01/2016	11/08/2016	11/02/2016
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04494	1649 W. BELMONT AVENUE	CHICAGO	IL	60657	10/15/2015	01/01/2016	11/08/2016	11/02/2016
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 11410	1627 N PULASKI RD	CHICAGO	IL	60639	01/04/2017	04/01/2017	04/01/2025	04/01/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04938	4748 W NORTH AVE	CHICAGO	IL	60639	01/04/2017	04/01/2017	04/01/2025	04/01/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01310	3110 W ARMITAGE	CHICAGO	IL	60647	01/04/2017	04/01/2017	04/01/2025	04/01/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04233	5600 W. FULLERTON	CHICAGO	IL	60639	01/04/2017	04/01/2017	04/01/2025	04/01/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04986	4745 W BELMONT AVE	CHICAGO	IL	60641-4410	01/10/2018	04/01/2018	04/01/2025	04/01/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03961	2340 W MADISON ST	CHICAGO	IL	60612	04/08/2019	07/01/2019	04/01/2025	04/01/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03395	3401 W ROOSEVELT RD	CHICAGO	IL	60624	04/08/2019	07/01/2019	07/29/2020	08/14/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04147	1546 N. CENTRAL AVE.	CHICAGO	IL	60651-1259	04/08/2019	07/01/2019	07/29/2020	08/14/2020
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/18/2017	04/01/2017	01/01/2020	02/25/2020
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	04/14/2015	07/01/2015	07/19/2019	07/28/2019
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	10/15/2015	01/01/2016	08/09/2017	08/09/2017
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	06/28/2017	07/01/2017	04/01/2025	04/01/2025
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/22/2021	10/01/2021	04/04/2022	04/19/2022
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 05681	3311 N. PULASKI RD.	CHICAGO	IL	60641	07/26/2013	10/01/2013	07/27/2017	07/31/2017
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08732	2053 N MILWAUKEE AVE	CHICAGO	IL	60647	07/26/2013	10/01/2013	03/18/2017	04/11/2017
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08733	3552 W GRAND	CHICAGO	IL	60651	07/26/2013	10/01/2013	03/18/2017	04/11/2017
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08735	3940 WEST FULLERTON	CHICAGO	IL	60647	07/26/2013	10/01/2013	11/24/2018	11/28/2018
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08740	2427 W CHICAGO AVE	CHICAGO	IL	60622	07/26/2013	10/01/2013	11/24/2018	11/28/2018
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	04/15/2019	07/01/2019	12/17/2020	12/31/2020
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/17/2020	07/01/2020	04/01/2025	04/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	07/22/2021	10/01/2021	04/01/2025	04/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/04/2022	04/04/2022	04/01/2025	04/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/17/2020	07/01/2020	04/01/2025	04/01/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	07/22/2021	10/01/2021	04/01/2025	04/01/2025
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/15/2020	07/15/2020	04/01/2025	04/01/2025
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/22/2021	10/01/2021	04/01/2025	04/01/2025
Contract Detail	PRESENCE CHICAGO HOSPITALS NETWORK	DBA AMITA HEALTH HOME INFUSION PHARMACY	7435 W TALCOTT AVE STE T1289	CHICAGO	IL	60631	01/03/2022	04/01/2022	04/01/2025	04/01/2025
Contract Detail	PRESENCE NAZARETH FAMILY CENTER	PHARMACY	1127 N. OAKLEY BLVD	CHICAGO	IL	60622	07/01/2004	07/01/2004	04/01/2025	04/01/2025
Contract Detail	PRESENCE SAINT JOSEPH HOSPITAL-CHICAGO	PHARMACY	2900 N LAKE SHORE DR	CHICAGO	IL	60657-5640	10/24/2012	10/24/2012	12/01/2024	12/04/2024
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/13/2017	10/01/2017	01/05/2023	01/17/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/03/2018	10/01/2018	01/01/2020	02/25/2020
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/04/2022	07/01/2022	10/19/2023	10/19/2023
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/15/2019	07/01/2019	04/01/2025	04/01/2025
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/15/2019	07/01/2019	04/01/2025	04/01/2025
Contract Detail	SINA DRUG LLC	DBA ONCO360	7125 JANES AVE STE 700	WOODRIDGE	IL	60517	10/07/2020	01/01/2021	04/01/2025	04/01/2025
Contract Detail	SORKIN'S RX LTD	D/B/A CAREMED PHARMACEUTICAL SERVICES	1985 MARCUS AVE STE 130	NEW HYDE PARK	NY	11042-2024	04/15/2019	07/01/2019	12/17/2020	12/31/2020
Contract Detail	WAL-MART PHARMACY 10-5402	4650 WEST NORTH AVE		CHICAGO	IL	60639	09/14/2012	09/14/2012	07/01/2015	05/13/2016
Contract Detail	WAL-MART PHARMACY 10-5647		570 W MONROE	CHICAGO	IL	60661	09/14/2012	09/14/2012	07/01/2015	05/13/2016
Contract Detail	WALGREEN CO	DBA: WALGREENS #15281	2817 N CLARK ST	CHICAGO	IL	60657	10/15/2015	01/01/2016	10/01/2019	10/14/2019
Contract Detail	WALGREEN CO	DBA: WALGREENS #15525	201 E. HURON STREET, SUITE 01-210	CHICAGO	IL	60611	07/13/2017	10/01/2017	10/01/2019	10/14/2019
Contract Detail	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	01/17/2023	04/01/2023	04/01/2025	04/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00178	740 W DIVERSEY PKWY	CHICAGO	IL	60614	10/15/2015	01/01/2016	11/08/2016	11/02/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00258	1650 W CHICAGO AVE	CHICAGO	IL	60622	10/15/2015	01/01/2016	04/01/2025	04/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01096	3646 N BROADWAY	CHICAGO	IL	60613	10/15/2015	01/01/2016	10/01/2019	10/14/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03949	3046 N HALSTED ST	CHICAGO	IL	60657	10/15/2015	01/01/2016	10/01/2019	10/14/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06270	1001 W BELMONT	CHICAGO	IL	60657	10/15/2015	01/01/2016	11/08/2016	11/02/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09000	2001 N MILWAUKEE AVE	CHICAGO	IL	60647-4001	10/15/2015	01/01/2016	04/01/2025	04/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15004	953 W. IRVING PARK RD.	CHICAGO	IL	60613	10/15/2015	01/01/2016	11/08/2016	11/02/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15065	1601 N. MILWAUKEE AVE.	CHICAGO	IL	60647-5411	10/15/2015	01/01/2016	03/24/2023	03/27/2023
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #15305	912 W BELMONT AVE	CHICAGO	IL	60657	10/15/2015	01/01/2016	11/08/2016	11/07/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15493	1333 W. BELMONT AVENUE	CHICAGO	IL	60657	10/15/2015	01/01/2016	11/08/2016	11/02/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #21447	3513 N HALSTED ST	CHICAGO	IL	60657	10/15/2015	01/01/2016	11/08/2016	11/02/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12304	2744 N. CALIFORNIA AVE	CHICAGO	IL	60647	01/04/2017	04/01/2017	04/01/2025	04/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07687	3320 W FULLERTON AVE	CHICAGO	IL	60647-2514	01/04/2017	04/01/2017	04/01/2025	04/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09470	4817 W FULLERTON AVE	CHICAGO	IL	60639-2503	01/04/2017	04/01/2017	04/01/2025	04/01/2025
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	01/04/2017	04/01/2017	04/18/2019	04/19/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07359	3222 N. MILWAUKEE AVENUE	CHICAGO	IL	60618-5106	07/13/2017	10/01/2017	04/01/2025	04/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10649	3424 W BELMONT AVE	CHICAGO	IL	60618	01/10/2018	04/01/2018	04/01/2025	04/01/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03948	5140 W DIVERSEY AVE	CHICAGO	IL	60639	04/08/2019	07/01/2019	04/01/2025	04/01/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/15/2015	01/01/2016	04/01/2025	04/01/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	10/15/2015	01/01/2016	11/10/2021	11/17/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/15/2015	01/01/2016	04/01/2025	04/01/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/15/2015	01/01/2016	04/01/2025	04/01/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140180A	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	Oncology Infusion Center: A service of Saints Mary and Elizabeth Medical Center	ST JOSEPH HOSP CHEMO DOP 340B	Chicago	IL	Terminated
DSH140180B	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	PSMEMC d/b/a Presence Saint Elizabeth Hospital - Surgery	1431 N. Claremont	Chicago	IL	Terminated
DSH140180C	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	PSMEMC d/b/a Saint Elizabeth Hospital - OP Oncology	2216 West Thomas Street	Chicago	IL	Terminated
DSH140180D	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	OP Behavioral Health	1431 N. Claremont	Chicago	IL	Terminated
DSH140180E	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	OP Behavioral Health	1127 N. OAKLEY BLVD	Chicago	IL	Terminated
DSH140180F	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	PSMEMC Infusion	5600 West Addison Street	Chicago	IL	Terminated
DSH140180G	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	Rheumatology - Rheumatology	1431 N. Claremont Ave	Chicago	IL	Terminated
DSH140180H	Child	DSH	Presence Saints Mary and Elizabeth Medical Center	Rheumatology - Rheumatology	2222 W. Division Street	Chicago	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/28/2025 12:00:00 AM	3/3/2025 6:24 AM
Details	State	Update	Termination Request	Active	To Be Terminated	3/3/2025 6:24 AM
Terminations	Termination Date	Update	Termination Request		4/1/2025 12:00:00 AM	3/3/2025 6:24 AM
Terminations	Termination Effective Date	Update	Termination Request		3/1/2025 12:00:00 AM	3/3/2025 6:24 AM
Terminations	Termination Reason	Update	Termination Request		For-Profit conversion	3/3/2025 6:24 AM
Details	Last Recertification Date	Update	Recertification	8/17/2023 9:57:41 AM	8/16/2024 7:13:52 AM	8/16/2024 7:13 AM
Addresses	Shipping Address	Delete	Change Request	Safecor Health 4060 Business Park Drive Columbus, OH 43204		6/24/2024 11:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/10/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		36-2235165	1/10/2024 8:30 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	1/10/2024 8:30 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	362235165018 (IL)		1/10/2024 8:30 AM
Addresses	Shipping Address	Insert	Change Request		Ascension RX 7701 Metropolis Drive 200C Austin, TX 78744	10/31/2023 1:39 PM
Details	Last Recertification Date	Update	Recertification	8/26/2022 7:20:06 AM	8/17/2023 9:57:41 AM	8/17/2023 9:57 AM
Contacts	Authorizing Official	Update	Change Request	Zornow, Eric M CFO Saints Mary and Elizabeth Medical Center 3127702105	Zornow, Eric CFO Ascension Saint Mary & Elizabeth MEdical Center 3127702105	11/3/2022 8:49 AM
Contacts	Primary Contact	Update	Group Change Request	Fischer, Rick System Director, 340B Amita Health 6303097828	Fischer, Rick 340B Program Director Ascension 6303097828	9/28/2022 12:19 PM
Details	Last Recertification Date	Update	Recertification	8/26/2021 10:15:38 AM	8/26/2022 7:20:06 AM	8/26/2022 7:20 AM
Contacts	Primary Contact	Update	Profile Change Request	Fischer, Rick System Director, 340B Amita Health 6309147828	Fischer, Rick System Director, 340B Amita Health 6303097828	1/20/2022 2:41 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	362235165418 (IL)		8/26/2021 10:15 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 12:12:43 PM	8/26/2021 10:15:38 AM	8/26/2021 10:15 AM
Addresses	Billing Address	Insert	Change Request		Ascension Health Ministry Service Center PO Box 33902 Indianapolis, IN 46203	5/19/2021 4:01 PM
Addresses	Shipping Address	Insert	Change Request		Safecor Health 4060 Business Park Drive Columbus, OH 43204	4/12/2021 12:55 PM
Contacts	Authorizing Official	Update	Change Request	Mulay, Michael James CFO AMITA Health Sts Mary and Elizabeth Medical Center Chicago 3127702105	Zornow, Eric M CFO Saints Mary and Elizabeth Medical Center 3127702105	9/30/2020 7:11 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	362171079001 (IL)		8/26/2020 12:12 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	362235165014 (IL)		8/26/2020 12:12 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/26/2020 12:12 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 9:05:07 AM	8/26/2020 12:12:43 PM	8/26/2020 12:12 PM
Contacts	Authorizing Official	Update	Change Request	Mulay, Mike James CFO Presence Saints Mary and Elizabeth Medical Center 3127702105	Mulay, Michael James CFO AMITA Health Sts Mary and Elizabeth Medical Center Chicago 3127702105	11/18/2019 8:18 AM
Contacts	Primary Contact	Update	Change Request	Fischer, Rick System Director, 340B Presence Health 6309142872	Fischer, Rick System Director, 340B Amita Health 6309147828	11/14/2019 10:55 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 11:26:48 AM	9/5/2019 9:05:07 AM	9/5/2019 9:05 AM
Contacts	Authorizing Official	Update	Change Request	Benner, David System Vice President, Pharmacy and Laboratory Services Presence Health 6309142842	Mulay, Mike James CFO Presence Saints Mary and Elizabeth Medical Center 3127702105	9/27/2018 8:57 AM
Details	Last Recertification Date	Update	Recertification	11/29/2017 3:03:59 PM	8/22/2018 11:26:48 AM	8/22/2018 11:26 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/10/2018 1:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		362235165018	4/10/2018 1:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/10/2018 1:46 PM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/29/2017 3:03:59 PM	11/29/2017 3:03 PM
Contacts	Primary Contact	Update	Change Request	RICKER, RICHARD H. Regional Lead Pharmacist 3127702341	Fischer, Rick System Director, 340B Presence Health 6309142872	10/23/2017 9:47 AM
Contacts	Authorizing Official	Insert	Change Request		Benner, David System Vice President, Pharmacy and Laboratory Services Presence Health 6309142842	10/23/2017 6:14 AM
Addresses	Main Address	Insert			2233 WEST DIVISION STREET CHICAGO, IL 60622	6/8/2017 11:55 AM
Contacts	Primary Contact	Insert			RICKER, RICHARD H. Regional Lead Pharmacist 3127702341	6/8/2017 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			362235165014	6/8/2017 11:55 AM
Medicaid Billing	Medicaid: State	Insert			IL	6/8/2017 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/8/2017 11:55 AM
Medicaid Billing	Medicaid: Number	Insert			362235165418	6/8/2017 11:55 AM
Medicaid Billing	Medicaid: State	Insert			IL	6/8/2017 11:55 AM
Details	Last Recertification Date	Update		8/13/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 5:43 PM
Details	Last Recertification Date	Update		8/11/2014 12:00:00 AM	8/13/2015 12:00:00 AM	8/13/2015 2:26 PM
Medicaid Billing	NPI: Number	Update		1722177229	1922177229	8/11/2014 9:32 AM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	8/11/2014 12:00:00 AM	8/11/2014 9:32 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 10:25 PM
Details	Entity Name	Update		ST MARY OF NAZARETH HOSPITAL CENTER	Presence Saints Mary and Elizabeth Medical Center	4/9/2013 12:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/31/2012 2:09 PM
Medicaid Billing	Medicaid: Number	Insert			362171079001	12/31/2012 2:09 PM
Medicaid Billing	Medicaid: State	Insert			IL	12/31/2012 2:09 PM
Medicaid Billing	NPI: Number	Insert			1722177229	12/31/2012 2:09 PM
Dates	Participating Approval Date	Update		4/21/2008 12:37:29 PM	4/21/2008 12:00:00 AM	9/13/2012 2:56 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/15/2012 7:36 AM
Details	Last Recertification Date	Insert				4/21/2008 12:40 PM
Details	Grant Number	Insert				4/21/2008 12:40 PM
Details	340B ID	Insert			DSH140180	4/21/2008 12:40 PM
Details	Is Authorizing Official EHB Data	Insert				4/21/2008 12:40 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/21/2008 12:40 PM
Details	Medicare Provider Number	Insert			140180	4/21/2008 12:40 PM
Details	Entity Name	Insert			ST MARY OF NAZARETH HOSPITAL CENTER	4/21/2008 12:40 PM
Details	Program Code	Insert			DSH	4/21/2008 12:40 PM
Details	Entity Subname	Insert				4/21/2008 12:40 PM
Dates	Participating Approval Date	Insert			4/21/2008 12:37:29 PM	4/21/2008 12:40 PM
Details	State	Insert			Active	4/21/2008 12:40 PM
Dates	Registration Date	Insert			4/21/2008 12:00:00 AM	4/21/2008 12:40 PM
Dates	Signed By Date	Insert				4/21/2008 12:40 PM
Dates	Start Date	Insert			7/1/2003 12:00:00 AM	4/21/2008 12:40 PM
Terminations	Termination Comments	Insert				4/21/2008 12:40 PM
Terminations	Termination Date	Insert				4/21/2008 12:40 PM
Terminations	Termination Effective Date	Insert				4/21/2008 12:40 PM
Terminations	Termination Reason	Insert				4/21/2008 12:40 PM