Covered Entity Details

DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER (Active) - information as of 5/25/2025 1:14:42 AM

Main Details

Name

MOUNT SINAI HOSPITAL MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140018

Medicare Provider Number

140018

Additional Details

Current Program Status

Active

Registration Date

4/30/2008

Participating Start Date

10/1/2004

Participating Approval Date

4/30/2008

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

Sinai Health System
Sameer Shah, President, Mount Sinai Hospital Medical Center
(773) 257-2012

Primary Contact

Sinai Health System
Thomas Yu, System Director of Ambulatory Pharmacy Services
(773) 257-2486

Addresses

Street Address

2750 W 15TH PLACE
CHICAGO, IL 60608-1797

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	36-1509000	1871581314,1619059300,1518057769,1386733681,1932496114,1861024176

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	A CAALMAD PHARMACY	2839 W MADISON		CHICAGO	IL	60612	04/03/2014	07/01/2014	08/17/2016	02/22/2017
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/16/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/16/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/16/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/16/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/16/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/16/2024	10/01/2024		10/01/2024
Contract Detail	ACRO PHARMACEUTICAL SERVICES LLC	ACRO PHARMACEUTICAL SERVICES LLC	313 HENDERSON DR	SHARON HILL	PA	19079	10/13/2016	01/01/2017	07/22/2019	09/04/2019
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/18/2024	04/01/2024		04/01/2024
Contract Detail	AETNA SPECIALTY PHARMACY, LLC	503 SUNPORT LN		ORLANDO	FL	32809-7874	06/06/2019	06/06/2019	09/13/2019	10/15/2019
Contract Detail	AMERICAN DRUG STORES LLC	DBA OSCO DRUG 2602	3644 S ARCHER AVE	CHICAGO	IL	60609	04/17/2017	07/01/2017	12/04/2018	12/04/2018
Contract Detail	AMERICAN DRUG STORES LLC	DBA OSCO DRUG 3344	1220 S ASHLAND AVE	CHICAGO	IL	60608	04/17/2017	07/01/2017	12/04/2018	12/04/2018
Contract Detail	AMERICAN DRUG STORES LLC	DBA OSCO DRUG 2602	3644 S ARCHER AVE	CHICAGO	IL	60609	07/12/2019	10/01/2019	01/25/2021	04/18/2022
Contract Detail	AMERICAN DRUG STORES LLC	DBA OSCO DRUG 3344	1220 S ASHLAND AVE	CHICAGO	IL	60608	07/12/2019	10/01/2019	01/25/2021	04/18/2022
Contract Detail	AMERITA, INC.	10204 WERCH DR.	UNIT 301	WOODRIDGE	IL	60517-2537	10/16/2017	01/01/2018		10/16/2017
Contract Detail	AMIJAY CORPORATION	3441 W NORTH AVE	DBA LAPUJA PHARMACY	CHICAGO	IL	60647-4841	01/13/2020	04/01/2020		04/01/2020
Contract Detail	BIOLOGICS	BIOLOGICS BY MCKESSON	13000 WESTON PKWY, STE 105	CARY	NC	27513-2250	07/17/2020	08/28/2020		08/28/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03395	3401 W ROOSEVELT RD	CHICAGO	IL	60624	04/30/2012	04/30/2012	11/12/2024	12/06/2024
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01417	1931 W CERMAK RD	CHICAGO	IL	60608	04/30/2012	01/01/2013		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02903	5222 WEST MADISON ST	CHICAGO	IL	60644	04/30/2012	04/30/2012		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05234	5435 S KEDZIE AVE	CHICAGO	IL	60632	04/30/2012	04/30/2012		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04938	4748 W NORTH AVE	CHICAGO	IL	60639	04/30/2012	04/30/2012		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03961	2340 W MADISON ST	CHICAGO	IL	60612	04/30/2012	04/30/2012		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04461	501 W ROOSEVELT RD	CHICAGO	IL	60607	04/30/2012	04/30/2012	11/17/2016	02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05356	4710 S WESTERN AVE	CHICAGO	IL	60609	04/30/2012	04/30/2012		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04147	1546 N. CENTRAL AVE.	CHICAGO	IL	60651-1259	04/30/2012	04/30/2012		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01503	1926 W 35TH ST	CHICAGO	IL	60609	04/30/2012	04/30/2012		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 11410	1627 N PULASKI RD	CHICAGO	IL	60639	04/30/2012	04/30/2012		02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05103	5932 W. CERMAK RD	CICERO	IL	60804	04/30/2012	04/30/2012	11/17/2016	02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #11492	5414 S. ARCHER AVE	CHICAGO	IL	60638-3002	04/30/2012	04/30/2012	11/17/2016	02/22/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05235	6412 ROOSEVELT RD	OAK PARK	IL	60304-2135	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05076	6800 OGDEN AVE	BERWYN	IL	60402	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05034	6315 S KEDZIE AVE	CHICAGO	IL	60629	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #11492	5414 S. ARCHER AVE	CHICAGO	IL	60638-3002	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02711	7150 W ARCHER AVE	CHICAGO	IL	60638	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	WALGREENS # 16525	5401 S WENTWORTH AVE SUITE 5A1	CHICAGO	IL	60609	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05033	2015 E 79TH ST	CHICAGO	IL	60649	04/17/2020	07/01/2020	11/06/2024	12/06/2024
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03960	7200 ROOSEVELT RD	FOREST PARK	IL	60130	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05103	5932 W. CERMAK RD	CICERO	IL	60804	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05139	7945 W 95TH ST	HICKORY HILLS	IL	60457	04/17/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05089	7111 S WESTERN AVE	CHICAGO	IL	60636	04/23/2020	07/01/2020	02/17/2025	02/17/2025
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05123	10300 S. MICHIGAN AVE.	CHICAGO	IL	60628	04/23/2020	07/01/2020		07/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02558	14700 HALSTED ST	HARVEY	IL	60426	07/17/2020	08/28/2020	06/02/2021	06/07/2021
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04233	5600 W. FULLERTON	CHICAGO	IL	60639	07/17/2020	08/28/2020		08/28/2020
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	04/14/2018	07/01/2018	07/15/2020	07/17/2020
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	04/14/2018	07/01/2018	07/15/2020	07/17/2020
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	06/06/2019	06/07/2019		06/10/2019
Contract Detail	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	07/17/2020	08/28/2020	01/14/2024	01/31/2024
Contract Detail	CENTERWELL PHARMACY, INC.	10737 MARKS WAY		MIRAMAR	FL	33025	07/17/2020	08/28/2020	01/14/2024	01/31/2024
Contract Detail	CHICAGO KEDZIE DRUGS		4054 WEST NORTH AVENUE	CHICAGO	IL	60639	04/07/2014	07/01/2014	07/19/2016	02/22/2017
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	01/15/2014	04/01/2014	07/21/2019	07/21/2019
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/23/2023	01/01/2024		01/01/2024
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	07/18/2016	10/01/2016	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	06/29/2017	07/01/2017		06/29/2017
Contract Detail	DEL-KAR PHARMACY	3726 W 16TH ST		CHICAGO	IL	60623-2026	04/15/2013	07/01/2013	07/19/2016	02/22/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/17/2020	08/28/2020	07/17/2023	07/19/2023
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/16/2024	10/01/2024		10/01/2024
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/16/2024	10/01/2024		10/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/16/2024	10/01/2024		10/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/16/2024	10/01/2024		10/01/2024
Contract Detail	GENOA HEALTHCARE LLC	4423 N RAVENSWOOD AVE STE P100		CHICAGO	IL	60640	07/16/2024	10/01/2024		10/01/2024
Contract Detail	GENOA HEALTHCARE LLC	1400 W GREENLEAF AVE STE 101		CHICAGO	IL	60626	07/16/2024	10/01/2024		10/01/2024
Contract Detail	HEALTH RX	1952 WEST CERMAK ROAD		CHICAGO	IL	60608	04/03/2014	07/01/2014	07/19/2016	02/22/2017
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08515	1713 S ASHLAND	CHICAGO	IL	60608	07/12/2019	10/01/2019	08/15/2019	09/04/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA CVS/PHARMACY # 4094	3146 WEST MADISON	CHICAGO	IL	60612	07/12/2019	10/01/2019	08/15/2019	09/04/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08741	2634 S PULASKI	CHICAGO	IL	60623	07/12/2019	10/01/2019	06/07/2022	10/21/2022
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 04793	1211 W. ROOSEVELT RD.	CHICAGO	IL	60608	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17166	1940 W 33RD ST	CHICAGO	IL	60608	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17634	1101 W JACKSON BLVD	CHICAGO	IL	60607	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08740	2427 W CHICAGO AVE	CHICAGO	IL	60622	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16219	2901 S CICERO AVE	CICERO	IL	60804	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08738	741 W 31ST	CHICAGO	IL	60616	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08733	3552 W GRAND	CHICAGO	IL	60651	07/12/2019	10/01/2019	08/15/2019	09/04/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08742	5524 W CERMAK RD, STE 1	CICERO	IL	60804	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16999	4433 S PULASKI RD	CHICAGO	IL	60632	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 07125	5360 S. WESTERN AVE.	CHICAGO	IL	60609	07/12/2019	10/01/2019	08/15/2019	09/04/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08502	6315 S PULASKI RD STE 1	CHICAGO	IL	60629	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16285	7100 S CICERO AVE	CHICAGO	IL	60629	07/12/2019	10/01/2019		10/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17009	1154 S CLARK ST	CHICAGO	IL	60605	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02935	8712 SOUTH STONY ISLAND AVE.	CHICAGO	IL	60617	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 03163	345 MADISON ST.	OAK PARK	IL	60302	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 04979	7855 S. WESTERN AVE.	CHICAGO	IL	60620	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17167	2112 W PETERSON AVE	CHICAGO	IL	60659	04/23/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02827	600 NORTH MANNHEIM RD.	HILLSIDE	IL	60162	10/21/2022	01/01/2023		01/01/2023
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08529	3134 11TH STREET	ROCKFORD	IL	61109	10/21/2022	01/01/2023		01/01/2023
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06785	3343 W. MONTROSE AVE.	CHICAGO	IL	60618	10/21/2022	01/01/2023	06/15/2023	07/19/2023
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 07166	250 W. 144TH ST.	RIVERDALE	IL	60827	10/21/2022	01/01/2023		01/01/2023
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17169	800 BROADVIEW VILLAGE SQ	BROADVIEW	IL	60155	10/21/2022	01/01/2023		01/01/2023
Contract Detail	I.G.G. of AMERICA, Inc. d/b/a US Bioservices	514 PROGRESS DRIVE	SUITE X	LINTHICUM	MD	21090	06/11/2020	07/01/2020		07/01/2020
Contract Detail	KAPLANCARE PHARMACY		3600 W. ROOSEVELT ROAD	CHICAGO	IL	60624-4225	04/13/2014	07/01/2014	07/19/2016	02/22/2017
Contract Detail	KMART STORES OF IL LLC 3594		5050 S KEDZIE AVENUE	CHICAGO	IL	60632	04/19/2016	07/01/2016	07/19/2016	02/22/2017
Contract Detail	KMART STORES OF IL LLC 4235		7050 S PULASKI	CHICAGO	IL	60629	04/19/2016	07/01/2016	07/19/2016	02/22/2017
Contract Detail	KMART STORES OF IL LLC 4381	7325 W 79TH STREET		BRIDGEVIEW	IL	60455	04/19/2016	07/01/2016	07/19/2016	02/22/2017
Contract Detail	KMART STORES OF IL LLC 9339		4101 W 95TH STREET	OAK LAWN	IL	60453	04/19/2016	07/01/2016	07/19/2016	02/22/2017
Contract Detail	KMART STORES OF IL LLC 9348	4201 N HARLEM AVENUE		NORRIDGE	IL	60706	04/19/2016	07/01/2016	07/19/2016	02/22/2017
Contract Detail	LITTLE VILLAGE PHARMACY, INC	DBA PROPACK PHARMACY	2600 S 25TH AVE STE 110	BROADVIEW	IL	60155	04/04/2014	07/01/2014	07/19/2016	02/22/2017
Contract Detail	MEXICARE INC.	3200 W 26TH ST		CHICAGO	IL	60623-4031	04/03/2014	07/01/2014	07/19/2016	02/22/2017
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	02/01/2013	04/01/2013		02/22/2017
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/14/2018	07/01/2018	10/23/2020	09/03/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/19/2023	10/01/2023		10/01/2023
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	07/16/2024	10/01/2024		10/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	07/16/2024	10/01/2024		10/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	01/09/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/11/2018	07/01/2018		04/11/2018
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/11/2018	07/01/2018		04/11/2018
Contract Detail	OPTUM PHARMACY 705, LLC	11142 RENNER BLVD		LENEXA	KS	66219	07/12/2019	10/01/2019	06/02/2021	06/07/2021
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	07/16/2024	10/01/2024		10/01/2024
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	07/16/2024	10/01/2024		10/01/2024
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	04/14/2018	07/01/2018		04/14/2018
Contract Detail	OPTUM PHARMACY 801, INC.	23620 N 20TH DR STE 12		PHOENIX	AZ	85085-0621	07/12/2019	10/01/2019	07/15/2020	07/17/2020
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/12/2019	10/01/2019		10/01/2019
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/16/2024	10/01/2024		10/01/2024
Contract Detail	PALCARE INC	MEXICARE PHARMACY II	1848 S. BLUE ISLAND AVE	CHICAGO	IL	60608	07/02/2014	10/01/2014	07/19/2016	02/22/2017
Contract Detail	PEE DEE KAY		DBA KEDZIE-MADISON DRUGS 3179 W MADISON	CHICAGO	IL	60612	07/02/2014	10/01/2014	07/19/2016	02/22/2017
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	10/15/2019	01/01/2020	10/01/2022	10/21/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	06/06/2019	06/07/2019		06/10/2019
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2751	426 S. HENDERSON STREET	FORT WORTH	TX	76104	06/06/2019	06/07/2019		06/10/2019
Contract Detail	PROMED PHARMACY, INC	3600 W ROOSEVELT RD		CHICAGO	IL	60624	04/04/2014	07/01/2014	07/19/2016	02/22/2017
Contract Detail	ROUNDY'S SUPERMARKETS INC	DBA MARIANO'S PHARMACY #8520	3145 S ASHLAND AVE	CHICAGO	IL	60608	01/13/2020	04/01/2020	05/20/2021	04/18/2022
Contract Detail	ROUNDY'S SUPERMARKETS INC	DBA MARIANO'S PHARMACY #8529	4700 GILBERT AVE #14	WESTERN SPRINGS	IL	60558	01/13/2020	04/01/2020	05/20/2021	04/18/2022
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	03/15/2013	04/01/2013		02/22/2017
Contract Detail	SINA DRUG LLC	DBA ONCO360	7125 JANES AVE STE 700	WOODRIDGE	IL	60517	11/30/2020	12/02/2020		12/02/2020
Contract Detail	SINAI COMMUNITY PHARMACY INC	2750 W 15TH PL STE C1120		CHICAGO	IL	60608	02/27/2013	04/01/2013		02/22/2017
Contract Detail	SORKIN'S RX LTD	D/B/A CAREMED PHARMACEUTICAL SERVICES	1985 MARCUS AVE STE 130	NEW HYDE PARK	NY	11042-2024	04/14/2018	07/01/2018		04/14/2018
Contract Detail	SURECARE PHARMACY INC.	2001 S CALIFORNIA AVE	SUITE 103	CHICAGO	IL	60608-2486	04/02/2014	07/01/2014	07/19/2016	02/22/2017
Contract Detail	SVS ENTERPRISE	SVS ENTERPRISE INC	3900 W MADISON ST STE 13	CHICAGO	IL	60624	07/11/2014	10/01/2014	08/17/2016	02/22/2017
Contract Detail	US BIOSERVICES	US BIOSERVICE CORPORATION	5025 PLANO PARKWAY STE 100	CARROLLTON	TX	75010	07/12/2019	10/01/2019		10/01/2019
Contract Detail	US BIOSERVICES	501 W. 44TH AVENUE	SUITE A	DENVER	CO	80216-2611	06/11/2020	07/01/2020		07/01/2020
Contract Detail	VIKOL PHARMACY	3752 W 16TH ST		CHICAGO	IL	60623	04/09/2014	07/01/2014	07/19/2016	02/22/2017
Contract Detail	VITAL RX, LLC	3110 W BELMONT AVE STE 1W		CHICAGO	IL	60618	07/18/2016	10/01/2016		02/22/2017
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/11/2017	10/01/2017		10/01/2017
Contract Detail	WAL-MART PHARMACY 10-1938	7050 SOUTH CICERO AVENUE		BEDFORD PARK	IL	60638	02/28/2013	04/01/2013	07/19/2016	02/22/2017
Contract Detail	WAL-MART PHARMACY 10-2204	1300 DES PLAINES AVENUE		FOREST PARK	IL	60130	02/28/2013	04/01/2013	08/17/2016	02/22/2017
Contract Detail	WAL-MART PHARMACY 10-2204	1300 DES PLAINES AVENUE		FOREST PARK	IL	60130	02/28/2013	04/01/2013	08/17/2016	02/22/2017
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	10/15/2019	01/01/2020		01/01/2020
Contract Detail	WAL-MART PHARMACY 10-5402	4650 WEST NORTH AVE		CHICAGO	IL	60639	02/28/2013	04/01/2013		02/22/2017
Contract Detail	WAL-MART PHARMACY 10-5485	2500 W. 95TH ST.		EVERGREEN PARK	IL	60805	01/08/2014	04/01/2014	07/19/2016	02/22/2017
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/11/2017	10/01/2017		10/01/2017
Contract Detail	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	01/27/2023	04/01/2023		04/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01249	4800 W CERMAK RD	CICERO	IL	60804	04/30/2012	04/30/2012	11/06/2024	12/06/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00215	3045 W 26TH STREET	CHICAGO	IL	60623	04/30/2012	04/30/2012		02/22/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00226	4005 W 26TH STREET	CHICAGO	IL	60623	04/30/2012	04/30/2012	02/18/2025	02/18/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00232	3405 S KING DR	CHICAGO	IL	60616	04/30/2012	04/30/2012	11/17/2016	02/22/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05926	4385 S ARCHER AVE	CHICAGO	IL	60632	04/30/2012	04/30/2012		02/22/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06641	1614 W 47TH STREET	CHICAGO	IL	60609-3245	04/30/2012	04/30/2012		02/22/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05867	3943 W 47TH STREET	CHICAGO	IL	60632-4145	04/30/2012	04/30/2012		02/22/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05868	3798 SOUTH WESTERN AVE	CHICAGO	IL	60609-1014	04/30/2012	04/30/2012	03/07/2016	02/22/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15506	3303 W. 26TH STREET SUITE 101	CHICAGO	IL	60623	04/17/2015	07/01/2015		02/22/2017
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	01/11/2016	04/01/2016		02/22/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15507	3800 W MADISON STREET SUITE 101	CHICAGO	IL	60624	10/16/2017	01/01/2018		10/16/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05825	1213 W 79TH STREET	CHICAGO	IL	60620-3706	04/17/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00163	4000 W 59TH ST	CHICAGO	IL	60629	04/17/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06297	6016 W 63RD STREET	CHICAGO	IL	60638-4318	04/17/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10485	12854 S ASHLAND AVE	CALUMET PARK	IL	60827-6308	04/17/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05192	9148 S COMMERCIAL AVE	CHICAGO	IL	60617	04/17/2020	07/01/2020	02/20/2025	02/20/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01450	4101 1ST AVE	LYONS	IL	60534	04/17/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06762	11833 S WESTERN AVE	CHICAGO	IL	60643-4734	04/17/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 11154	7113 CERMAK RD	BERWYN	IL	60402	04/17/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03539	11 E 75TH STREET	CHICAGO	IL	60619	04/23/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07267	650 W 63RD ST	CHICAGO	IL	60621-2012	04/23/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05724	7045 S PULASKI ROAD	CHICAGO	IL	60629-5833	04/23/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06727	4720 N MARINE DRIVE	CHICAGO	IL	60640-5120	07/17/2020	08/28/2020		08/28/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09470	4817 W FULLERTON AVE	CHICAGO	IL	60639-2503	07/17/2020	08/28/2020		08/28/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06629	8701 S CICERO AVE	HOMETOWN	IL	60456-1018	07/17/2020	08/28/2020		08/28/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS #15971	259 E. ERIE STREET SUITE 250	CHICAGO	IL	60611	04/16/2021	07/01/2021		07/01/2021
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	04/16/2021	07/01/2021		07/01/2021
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #15305	912 W BELMONT AVE	CHICAGO	IL	60657	04/16/2021	07/01/2021		07/01/2021
Contract Detail	WALGREEN CO.	DBA WALGREENS #16093	3040 S. CICERO AVE. SUITE A	CICERO	IL	60804	01/27/2023	04/01/2023		04/01/2023
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/18/2016	10/01/2016		02/22/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/18/2016	10/01/2016	10/01/2021	10/21/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/18/2016	10/01/2016		02/22/2017
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/18/2016	10/01/2016		02/22/2017
Contract Detail	WALMART PHARMACY 10-3004	3320 S. CICERO AVE		CICERO	IL	60804	07/11/2014	10/01/2014	07/19/2016	02/22/2017
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/27/2023	04/01/2023		04/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/23/2023	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140018A	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Outpatient Spasticity Clinic at Schwab	1401 S California Ave	Chicago	IL	Active
DSH140018B	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	MSH SPECIALTY CLINIC AT SCHWAB	1414 South Fairfield Avenue	Chicago	IL	Active
DSH140018C	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	HEM/ONC CLINIC @ ARCHER	6084 South Archer Avenue	Chicago	IL	Terminated
DSH140018D	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Outpatient Chemotherapy	2750 W 15TH PLACE	CHICAGO	IL	Active
DSH140018E	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	MSH Specialty Clinic	2750 W 15TH PLACE	CHICAGO	IL	Active
DSH140018F	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Renal Dialysis	2642 W OGDEN AVE	CHICAGO	IL	Active
DSH140018G	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Adult OP Behavioral Health - Behavioral Health	2653 West Ogden Avenue	Chicago	IL	Active
DSH140018H	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Under the Rainbow - Behavioral Health	2750 W 15th Place	Chicago	IL	Active
DSH140018J	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	GI Pre-Post Op - Gastroenterology (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active
DSH140018K	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	GI At Ogden Comm - Gastroenterology (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active
DSH140018L	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	OR Pre-Post Op - Surgery (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active
DSH140018M	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	Outpatient Surgery at Ogden Commons - Surgery (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active
DSH140018N	Child	DSH	MOUNT SINAI HOSPITAL MEDICAL CENTER	GI Clinic Ogden - Gastroenterology (Ogden Commons)	2642 W OGDEN AVE	Chicago	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Shah, Sameer Vice President, Clinical & Professional Services Sinai Health System 7732572012	Shah, Sameer President, Mount Sinai Hospital Medical Center Sinai Health System 7732572012	4/9/2025 11:25 AM
Details	Last Recertification Date	Update	Recertification	8/31/2023 4:45:31 PM	9/6/2024 11:24:09 AM	9/6/2024 11:24 AM
Details	Last Recertification Date	Update	Recertification	9/15/2022 7:32:19 AM	8/31/2023 4:45:31 PM	8/31/2023 4:45 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 3:31:00 PM	9/15/2022 7:32:19 AM	9/15/2022 7:32 AM
Details	Last Recertification Date	Update	Recertification	8/31/2020 4:41:08 PM	9/7/2021 3:31:00 PM	9/7/2021 3:31 PM
Contacts	Authorizing Official	Update	AO Change Request	Mazurek, Michele Hospital Chief Administator Mount Sinai Medical Center 7732575021	Shah, Sameer Vice President, Clinical & Professional Services Sinai Health System 7732572012	5/27/2021 6:26 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/31/2020 4:41 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1861024176	8/31/2020 4:41 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	8/31/2020 4:41 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/31/2020 4:41 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/31/2020 4:41 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/31/2020 4:41 PM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/31/2020 4:41 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 8:59:49 AM	8/31/2020 4:41:08 PM	8/31/2020 4:41 PM
Contacts	Primary Contact	Update	Profile Change Request	Yu, Thomas Outpatient Pharmacy Manager Sinai Health System 7732572486	Yu, Thomas System Director of Ambulatory Pharmacy Services Sinai Health System 7732572486	2/20/2020 6:39 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1932496114	1/31/2020 7:38 PM
Contacts	Primary Contact	Update	Change Request	Austin, Donnica Lynn Vice President of Operations, Acute Care Hospitals Sinai Health System 7732575048	Yu, Thomas Outpatient Pharmacy Manager Sinai Health System 7732572486	1/31/2020 7:38 PM
Contacts	Authorizing Official	Update	AO Change Request	Pacura, Lori President of Acute Care Hospitals Sinai Health System 7732572914	Mazurek, Michele Hospital Chief Administator Mount Sinai Medical Center 7732575021	1/2/2020 7:08 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1871581314 ( )		9/5/2019 8:59 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 9:57:21 AM	9/5/2019 8:59:49 AM	9/5/2019 8:59 AM
Details	Last Recertification Date	Update	Recertification	11/8/2017 3:15:49 PM	9/6/2018 9:57:21 AM	9/6/2018 9:57 AM
Contacts	Authorizing Official	Update	AO Change Request	Chandler, Loren EVP COO Sinai Health System 7732575658	Pacura, Lori President of Acute Care Hospitals Sinai Health System 7732572914	8/28/2018 7:17 AM
Contacts	Primary Contact	Update	Change Request	SCHNEIDER, JUSTIN VICE PRESIDENT CLINICAL OPERATIONS Mount Sinai Hospital Medical Center 7732575048	Austin, Donnica Lynn Vice President of Operations, Acute Care Hospitals Sinai Health System 7732575048	4/2/2018 2:25 PM
Details	Last Recertification Date	Update	Recertification	8/19/2016 12:00:00 AM	11/8/2017 3:15:49 PM	11/8/2017 3:15 PM
Contacts	Authorizing Official	Insert	AO Change Request		Chandler, Loren EVP COO Sinai Health System 7732575658	10/30/2017 8:57 AM
Contacts	Primary Contact	Update		SCHNEIDER, JUSTIN VICE PRESIDENT CLINICAL OPERATIONS 7732575048	SCHNEIDER, JUSTIN VICE PRESIDENT CLINICAL OPERATIONS Mount Sinai Hospital Medical Center 7732575048	10/10/2017 10:32 AM
Contacts	Primary Contact	Update		SCHNEIDER, JUSTIN DIRECTOR OF PHARMACY 7732575048	SCHNEIDER, JUSTIN VICE PRESIDENT CLINICAL OPERATIONS 7732575048	2/22/2017 9:51 AM
Addresses	Main Address	Insert			2750 W 15TH PLACE CHICAGO, IL 60608-1797	2/22/2017 9:51 AM
Details	Last Recertification Date	Update		8/27/2015 12:00:00 AM	8/19/2016 12:00:00 AM	8/19/2016 2:11 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/27/2015 5:09 PM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	8/27/2015 12:00:00 AM	8/27/2015 5:09 PM
Details	Last Recertification Date	Update		8/30/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 6:43 AM
Contacts	Primary Contact	Insert			SCHNEIDER, JUSTIN DIRECTOR OF PHARMACY 7732575048	7/3/2014 4:20 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/30/2013 12:00:00 AM	8/30/2013 7:49 PM
Medicaid Billing	NPI: Number	Insert			1871581314	5/15/2012 7:32 AM
Medicaid Billing	NPI: Number	Insert			1871581314	5/15/2012 7:32 AM
Medicaid Billing	NPI: Number	Insert			1619059300	5/15/2012 7:32 AM
Medicaid Billing	NPI: Number	Insert			1518057769	5/15/2012 7:32 AM
Medicaid Billing	NPI: Number	Insert			1386733681	5/15/2012 7:32 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/15/2012 7:32 AM
Details	Last Recertification Date	Insert				4/30/2008 4:08 PM
Details	Grant Number	Insert				4/30/2008 4:08 PM
Details	340B ID	Insert			DSH140018	4/30/2008 4:08 PM
Details	Is Authorizing Official EHB Data	Insert				4/30/2008 4:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/30/2008 4:08 PM
Details	Medicare Provider Number	Insert			140018	4/30/2008 4:08 PM
Details	Entity Name	Insert			MOUNT SINAI HOSPITAL MEDICAL CENTER	4/30/2008 4:08 PM
Details	Program Code	Insert			DSH	4/30/2008 4:08 PM
Details	Entity Subname	Insert				4/30/2008 4:08 PM
Dates	Participating Approval Date	Insert			4/30/2008 4:05:00 PM	4/30/2008 4:08 PM
Details	State	Insert			Active	4/30/2008 4:08 PM
Dates	Registration Date	Insert			4/30/2008 12:00:00 AM	4/30/2008 4:08 PM
Dates	Signed By Date	Insert				4/30/2008 4:08 PM
Dates	Start Date	Insert			10/1/2004 12:00:00 AM	4/30/2008 4:08 PM
Terminations	Termination Comments	Insert				4/30/2008 4:08 PM
Terminations	Termination Date	Insert				4/30/2008 4:08 PM
Terminations	Termination Effective Date	Insert				4/30/2008 4:08 PM
Terminations	Termination Reason	Insert				4/30/2008 4:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	4/30/2008 4:07 PM
Medicaid Billing	Medicaid: Number	Insert			36-1509000	4/30/2008 4:07 PM
Medicaid Billing	Medicaid: State	Insert			IL	4/30/2008 4:07 PM