| Details | Last Recertification Date | Update | Recertification | 2/15/2024 11:00:22 AM | 2/24/2025 8:57:46 AM | 2/24/2025 8:57 AM |
| Addresses | Main Address | Update | Group Change Request |
N15019 Hannahville Road B 1
Wilson, MI 49896 |
N15750 Hannahville Road B-1
Wilson, MI 49896 | 1/21/2025 7:39 AM |
| Contacts | Primary Contact | Update | Group Change Request | Bernson, Todd
Pharmacy Manager
Hannahville Indian Community
9067232560 | Varoni, Nichole
Nurse-Patient Care & Compliance
Hannahville Health Center
9064662782 | 1/21/2025 7:39 AM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2023 11:21:08 AM | 2/15/2024 11:00:22 AM | 2/15/2024 11:00 AM |
| Details | Last Recertification Date | Update | Recertification | 2/11/2022 3:12:18 PM | 2/3/2023 11:21:08 AM | 2/3/2023 11:21 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Meshigaud, G Susan
Director of Health and Human Services
Hannahville Health Center Pharmacy
9067232500 | Meshigaud, G Susan
Director of Health and Human Services
Hannahville Health Center
9067232500 | 2/2/2023 4:04 PM |
| Details | Last Recertification Date | Update | Recertification | 2/11/2021 10:03:16 AM | 2/11/2022 3:12:18 PM | 2/11/2022 3:12 PM |
| Details | Last Recertification Date | Update | Recertification | 2/19/2020 1:00:33 PM | 2/11/2021 10:03:16 AM | 2/11/2021 10:03 AM |
| Contacts | Authorizing Official | Update | New Registration | Meshigaud, G Susan
Director of Health and Human Services
Hannahville Health Center Pharmacy
9067232500 | Meshigaud, G Susan
Director of Health and Human Services
Hannahville Health Center Pharmacy
9067232500 | 1/14/2021 3:03 PM |
| Details | Entity Subname | Update | Change Request | | Family practice/dental/behavioral health | 1/12/2021 9:18 AM |
| Details | Last Recertification Date | Update | Recertification | 2/20/2019 2:26:11 PM | 2/19/2020 1:00:33 PM | 2/19/2020 1:00 PM |
| Details | Last Recertification Date | Update | Recertification | 3/7/2018 2:23:27 PM | 2/20/2019 2:26:11 PM | 2/20/2019 2:26 PM |
| Addresses | Shipping Address | Insert | Recertification | | Hannahville Health Center Pharmacy
W365 US 2& 41
Suite 600
Wilson, MI 49896 | 3/7/2018 2:23 PM |
| Addresses | Main Address | Update | Recertification |
W 365 US 2 & 41
Suite 600
Wilson, MI 49896 |
N15019 Hannahville Road B 1
Wilson, MI 49896 | 3/7/2018 2:23 PM |
| Contacts | Primary Contact | Update | Recertification | Young, Aaron
Pharmacist
9047232560 | Bernson, Todd
Pharmacy Manager
Hannahville Indian Community
9067232560 | 3/7/2018 2:23 PM |
| Details | Last Recertification Date | Update | Recertification | 1/25/2017 12:00:00 AM | 3/7/2018 2:23:27 PM | 3/7/2018 2:23 PM |
| Details | Entity Name | Update | Recertification | HANNAHVILLE HEALTH CENTER PHARMACY | HANNAHVILLE HEALTH CENTER | 3/7/2018 2:23 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Young, Aaron
Pharmacist
9047232560 | Meshigaud, G Susan
Director of Health and Human Services
Hannahville Health Center Pharmacy
9067232500 | 3/7/2018 1:51 PM |
| Addresses | Main Address | Insert | | |
W 365 US 2 & 41
Suite 600
Wilson, MI 49896 | 1/25/2017 9:27 AM |
| Contacts | Authorizing Official | Insert | | | Young, Aaron
Pharmacist
9047232560 | 1/25/2017 9:27 AM |
| Contacts | Primary Contact | Insert | | | Young, Aaron
Pharmacist
9047232560 | 1/25/2017 9:27 AM |
| Details | Last Recertification Date | Update | | 2/12/2016 12:00:00 AM | 1/25/2017 12:00:00 AM | 1/25/2017 9:27 AM |
| Details | Entity Name | Update | | HANNAHVILLE INDIAN HEALTH CENTER | HANNAHVILLE HEALTH CENTER PHARMACY | 2/25/2016 2:41 PM |
| Medicaid Billing | Medicaid: Is Primary | Update | | True | False | 2/12/2016 8:57 AM |
| Details | Last Recertification Date | Update | | 1/29/2015 12:00:00 AM | 2/12/2016 12:00:00 AM | 2/12/2016 8:57 AM |
| Details | Last Recertification Date | Update | | 2/11/2014 12:00:00 AM | 1/29/2015 12:00:00 AM | 1/29/2015 12:28 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 2/11/2014 12:00:00 AM | 2/11/2014 10:12 AM |
| Details | Entity Subname | Update | | PHARMACY | | 3/1/2013 11:28 AM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/4/2013 1:05 PM |
| Details | Last Recertification Date | Insert | | | | 9/18/2002 12:00 AM |
| Details | Grant Number | Insert | | | | 9/18/2002 12:00 AM |
| Details | 340B ID | Insert | | | FQHC638159 | 9/18/2002 12:00 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 9/18/2002 12:00 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 9/18/2002 12:00 AM |
| Details | Medicare Provider Number | Insert | | | | 9/18/2002 12:00 AM |
| Details | Entity Name | Insert | | | HANNAHVILLE INDIAN HEALTH CENTER | 9/18/2002 12:00 AM |
| Details | Program Code | Insert | | | FQHC638 | 9/18/2002 12:00 AM |
| Details | Entity Subname | Insert | | | PHARMACY | 9/18/2002 12:00 AM |
| Dates | Participating Approval Date | Insert | | | 10/1/1997 12:00:00 AM | 9/18/2002 12:00 AM |
| Details | State | Insert | | | Active | 9/18/2002 12:00 AM |
| Dates | Registration Date | Insert | | | 10/1/1997 12:00:00 AM | 9/18/2002 12:00 AM |
| Dates | Signed By Date | Insert | | | | 9/18/2002 12:00 AM |
| Dates | Start Date | Insert | | | 10/1/1997 12:00:00 AM | 9/18/2002 12:00 AM |
| Terminations | Termination Comments | Insert | | | | 9/18/2002 12:00 AM |
| Terminations | Termination Date | Insert | | | | 9/18/2002 12:00 AM |
| Terminations | Termination Effective Date | Insert | | | | 9/18/2002 12:00 AM |
| Terminations | Termination Reason | Insert | | | | 9/18/2002 12:00 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | True | 10/1/1997 12:00 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 3318829 | 10/1/1997 12:00 AM |
| Medicaid Billing | Medicaid: State | Insert | | | MI | 10/1/1997 12:00 AM |