Covered Entity Details

CAH141304-00 Genesis Medical Center, Aledo (Active) - information as of 6/4/2025 12:03:12 PM

Main Details

Name

Genesis Medical Center, Aledo

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141304-00

Medicare Provider Number

141304

Additional Details

Current Program Status

Active

Registration Date

9/17/2010

Participating Start Date

9/28/2010

Participating Approval Date

9/28/2010

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Genesis Medical Center Aledo
Edward Rogalski, Administrator
(309) 582-3700

Primary Contact

Genesis Medical Center, Aledo
Elizabeth M DeWalsche, Pharmacist Supervisor
(309) 582-9184

Addresses

Street Address

409 NW 9TH AVE
ALEDO, IL 61231

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	454475683001,454475683	1225380967

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	GENESIS FIRSTMED PHARMACY	GENVENTURES INC	105 S COLLEGE AVE	ALEDO	IL	61231-1630	01/09/2017	01/10/2017		01/10/2017
Contract Detail	MCKNIGHT PHARMACY	109 SOUTH COLLEGE AVENUE	PO BOX 209	ALEDO	IL	61231	03/15/2013	04/01/2013	12/22/2016	12/22/2016
Contract Detail	MERCYONE GENESIS FIRSTMED SPECIALTY PHAR	GENVENTURES INC	1227 E RUSHOLME ST	DAVENPORT	IA	52803	10/01/2021	01/01/2022		04/14/2023
Contract Detail	STUTS DRUG STORE INC	RELANDER DAVID, PRESIDENT	105 S. COLLEGE AVENUE	ALEDO	IL	61231	03/15/2013	04/01/2013	04/14/2017	04/14/2017
Contract Detail	WAGNER PHARMACY	108 NORTH COLLEGE AVE		ALEDO	IL	61231	03/15/2013	04/01/2013	12/22/2016	12/22/2016
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/09/2019	07/01/2019		07/01/2019
Contract Detail	WAL-MART PHARMACY 10-0792	1500 S.E. 5TH ST		ALEDO	IL	61231	04/09/2019	07/01/2019		07/01/2019
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/09/2019	07/01/2019		07/01/2019
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/10/2023	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH141304-01	Child	CAH	Genesis Medical Center, Aledo	GMC Aledo - Genesis Health Group Clinic	1007 NW 3rd St.	Aledo	IL	Active
CAH141304-02	Child	CAH	Genesis Medical Center, Aledo	Medical Associates Clinic - Dicklin	409 NW 9th Avenue	Aledo	IL	Terminated
CAH141304-03	Child	CAH	Genesis Medical Center, Aledo	Medical Associates Clinic - Wurzburger	409 NW 9th Avenue	Aledo	IL	Terminated
CAH141304-06	Child	CAH	Genesis Medical Center, Aledo	GMC Aledo - Genesis Health Group Clinic	409 NW 9th Avenue	Aledo	IL	Terminated
CAH141304-07	Child	CAH	Genesis Medical Center, Aledo	Medical Associates Clinic - Gengler	409 NW 9th Avenue	Aledo	IL	Terminated
CAH141304-08	Child	CAH	Genesis Medical Center, Aledo	Medical Associates Clinic - Santiago	409 NW 9th Avenue	Aledo	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Rogalski, Edward Chief Executive Officer Genesis Medical Center Aledo 3095823700	Rogalski, Edward Administrator Genesis Medical Center Aledo 3095823700	12/19/2024 8:57 AM
Details	Last Recertification Date	Update	Recertification	8/25/2023 12:50:42 PM	8/26/2024 10:35:27 AM	8/26/2024 10:35 AM
Contacts	Primary Contact	Update	Group Change Request	DeWalsche, Elizabeth M Pharmacist Supervisor Genesis Medical Center, Aledo 3095829184	DeWalsche, Elizabeth M Pharmacist Supervisor Genesis Medical Center, Aledo 3095829184	7/29/2024 9:17 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 10:38:39 AM	8/25/2023 12:50:42 PM	8/25/2023 12:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/22/2023 9:52 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		454475683	6/22/2023 9:52 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/22/2023 9:52 AM
Details	Last Recertification Date	Update	Recertification	9/7/2021 9:29:50 AM	9/1/2022 10:38:39 AM	9/1/2022 10:38 AM
Contacts	Primary Contact	Update	PC Change Request	Philibert, John Pharmacy Manager Genesis Medical Center Aledo 3095829184	DeWalsche, Elizabeth M Pharmacist Supervisor Genesis Medical Center, Aledo 3095829184	4/25/2022 6:52 AM
Details	Last Recertification Date	Update	Recertification	9/7/2020 9:09:55 AM	9/7/2021 9:29:50 AM	9/7/2021 9:29 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/16/2020 12:39 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		454475683001	12/16/2020 12:39 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	12/16/2020 12:39 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1225380967	12/16/2020 12:39 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	12/16/2020 12:39 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	45-4475683001 (IL)		9/7/2020 9:09 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1225380967 ( )		9/7/2020 9:09 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 8:19:23 AM	9/7/2020 9:09:55 AM	9/7/2020 9:09 AM
Details	Last Recertification Date	Update	Recertification	8/21/2018 2:26:05 PM	8/29/2019 8:19:23 AM	8/29/2019 8:19 AM
Details	Last Recertification Date	Update	Recertification	11/21/2017 11:38:14 AM	8/21/2018 2:26:05 PM	8/21/2018 2:26 PM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	11/21/2017 11:38:14 AM	11/21/2017 11:38 AM
Contacts	Primary Contact	Update	Recertification	Philibert, John Pharmacy Manager 3095829184	Philibert, John Pharmacy Manager Genesis Medical Center Aledo 3095829184	11/21/2017 11:24 AM
Contacts	Authorizing Official	Update		Rogalski, Edward Chief Executive Officer 3095823700	Rogalski, Edward Chief Executive Officer Genesis Medical Center Aledo 3095823700	11/21/2017 11:17 AM
Contacts	Authorizing Official	Update		ROGALSKI, EDWARD CHIEF EXECUTIVE OFFICER 3095823700	Rogalski, Edward Chief Executive Officer 3095823700	4/14/2017 9:57 AM
Contacts	Primary Contact	Update		CRISWELL, JODIE CHIEF FINANCIAL OFFICER 3095823704	Philibert, John Pharmacy Manager 3095829184	9/6/2016 3:55 PM
Addresses	Main Address	Insert			409 NW 9TH AVE ALEDO, IL 61231	9/6/2016 3:09 PM
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 3:09 PM
Details	Last Recertification Date	Update		9/8/2014 12:00:00 AM	9/3/2015 12:00:00 AM	9/3/2015 11:27 AM
Medicaid Billing	Medicaid: Number	Update		366007544007	45-4475683001	9/8/2014 12:15 PM
Medicaid Billing	NPI: Number	Update		1053664938	1225380967	9/8/2014 12:15 PM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	9/8/2014 12:00:00 AM	9/8/2014 12:15 PM
Medicaid Billing	Medicaid: Number	Update		366007544401	366007544007	9/9/2013 9:17 PM
Medicaid Billing	NPI: Number	Update		1093715799	1053664938	9/9/2013 9:17 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 9:17 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/5/2013 11:29 AM
Medicaid Billing	Medicaid: Number	Insert			366007544401	2/5/2013 11:29 AM
Medicaid Billing	Medicaid: State	Insert			IL	2/5/2013 11:29 AM
Medicaid Billing	NPI: Number	Insert			1093715799	2/5/2013 11:29 AM
Details	Entity Name	Update		COUNTY OF MERCER HOSPITAL DBA MERCER COUNTY HOSPITAL	Genesis Medical Center, Aledo	2/5/2013 11:29 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	6/4/2012 12:04 PM
Contacts	Authorizing Official	Insert			ROGALSKI, EDWARD CHIEF EXECUTIVE OFFICER 3095823700	9/28/2010 2:45 PM
Contacts	Primary Contact	Insert			CRISWELL, JODIE CHIEF FINANCIAL OFFICER 3095823704	9/28/2010 2:45 PM
Details	Last Recertification Date	Insert				9/28/2010 2:45 PM
Details	Grant Number	Insert				9/28/2010 2:45 PM
Details	340B ID	Insert			CAH141304-00	9/28/2010 2:45 PM
Details	Is Authorizing Official EHB Data	Insert				9/28/2010 2:45 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/28/2010 2:45 PM
Details	Medicare Provider Number	Insert			141304	9/28/2010 2:45 PM
Details	Entity Name	Insert			COUNTY OF MERCER HOSPITAL DBA MERCER COUNTY HOSPITAL	9/28/2010 2:45 PM
Details	Program Code	Insert			CAH	9/28/2010 2:45 PM
Details	Entity Subname	Insert				9/28/2010 2:45 PM
Dates	Participating Approval Date	Insert			9/28/2010 12:00:00 AM	9/28/2010 2:45 PM
Details	State	Insert			Active	9/28/2010 2:45 PM
Dates	Registration Date	Insert			9/17/2010 12:00:00 AM	9/28/2010 2:45 PM
Dates	Signed By Date	Insert			9/17/2010 12:00:00 AM	9/28/2010 2:45 PM
Dates	Start Date	Insert			9/28/2010 12:00:00 AM	9/28/2010 2:45 PM
Terminations	Termination Comments	Insert				9/28/2010 2:45 PM
Terminations	Termination Date	Insert				9/28/2010 2:45 PM
Terminations	Termination Effective Date	Insert				9/28/2010 2:45 PM
Terminations	Termination Reason	Insert				9/28/2010 2:45 PM