| Medicaid Billing | NPI: Number | Insert | Change Request | | 1548254931 | 2/14/2025 12:19 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | OH | 2/14/2025 12:19 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Davis, Jessi Lee
Director of Pharmacy
Mary Rutan Hospital
9375997054 | Hines, Jessi Lee
Director of Pharmacy
Mary Rutan Hospital
9375997054 | 12/17/2024 8:15 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2023 4:35:48 PM | 8/15/2024 11:23:30 AM | 8/15/2024 11:23 AM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2022 1:42:59 PM | 8/30/2023 4:35:48 PM | 8/30/2023 4:35 PM |
| Contacts | Authorizing Official | Update | Change Request | Brown, Steven R.
CFO, VP FINANCIAL SERVICES
Mary Rutan Hospital
9375997001 | Denbow, Thomas
VP of Finance and Development
Mary Rutan Hospital
9376516688 | 8/15/2023 1:06 PM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2021 3:50:45 PM | 9/1/2022 1:42:59 PM | 9/1/2022 1:42 PM |
| Contacts | Primary Contact | Update | Change Request | Myers, Christina Marie
Director of Pharmacy
Mary Rutan Hospital
9375997054 | Davis, Jessi Lee
Director of Pharmacy
Mary Rutan Hospital
9375997054 | 9/7/2021 9:12 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2020 8:26:20 AM | 8/25/2021 3:50:45 PM | 8/25/2021 3:50 PM |
| Addresses | Shipping Address | Delete | Recertification | Mary Rutan Hospital Retail Pharmacy
205 E PALMER ROAD
BELLEFONTAINE, OH 43311 | | 8/26/2020 8:26 AM |
| Addresses | Shipping Address | Insert | Recertification | | Mary Rutan Hospital Pharmacy
205 E PALMER ROAD
BELLEFONTAINE, OH 43311 | 8/26/2020 8:26 AM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2019 1:33:09 PM | 8/26/2020 8:26:20 AM | 8/26/2020 8:26 AM |
| Details | Last Recertification Date | Update | Recertification | 9/5/2018 10:12:36 AM | 8/19/2019 1:33:09 PM | 8/19/2019 1:33 PM |
| Details | Last Recertification Date | Update | Recertification | 11/8/2017 2:33:51 PM | 9/5/2018 10:12:36 AM | 9/5/2018 10:12 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Myers, Christina Marie
Director of Pharmacy
Mary Rutan Hospital
9375996491 | Myers, Christina Marie
Director of Pharmacy
Mary Rutan Hospital
9375997054 | 7/11/2018 12:43 PM |
| Contacts | Primary Contact | Update | | Myers, Christina
Director of Pharmacy
Mary Rutan Hospital
9375996491 | Myers, Christina Marie
Director of Pharmacy
Mary Rutan Hospital
9375996491 | 12/27/2017 12:09 PM |
| Contacts | Primary Contact | Update | Change Request | Hunsicker, Melannie L.
Director of Pharmacy
Mary Rutan Hospital
9375997054 | Myers, Christina
Director of Pharmacy
Mary Rutan Hospital
9375996491 | 12/26/2017 8:21 AM |
| Contacts | Primary Contact | Insert | Recertification | | Hunsicker, Melannie L.
Director of Pharmacy
Mary Rutan Hospital
9375997054 | 11/8/2017 2:33 PM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2016 12:00:00 AM | 11/8/2017 2:33:51 PM | 11/8/2017 2:33 PM |
| Contacts | Authorizing Official | Update | | Brown, Steven R.
CFO, VP FINANCIAL SERVICES
9375997001 | Brown, Steven R.
CFO, VP FINANCIAL SERVICES
Mary Rutan Hospital
9375997001 | 10/2/2017 12:25 PM |
| Contacts | Authorizing Official | Insert | | | Brown, Steven R.
CFO, VP FINANCIAL SERVICES
9375997001 | 10/28/2016 10:44 AM |
| Addresses | Main Address | Insert | | |
205 E PALMER ROAD
BELLEFONTAINE, OH 43311 | 10/28/2016 10:44 AM |
| Addresses | Billing Address | Insert | | | MARY RUTAN HOSPITAL
P.O. BOX 951434
CLEVELAND, OH 44193 | 10/28/2016 10:44 AM |
| Addresses | Shipping Address | Insert | | | Mary Rutan Hospital Retail Pharmacy
205 E PALMER ROAD
BELLEFONTAINE, OH 43311 | 10/28/2016 10:44 AM |
| Details | Last Recertification Date | Update | | 8/5/2015 12:00:00 AM | 8/17/2016 12:00:00 AM | 8/17/2016 10:20 AM |
| Details | Last Recertification Date | Update | | 9/4/2014 12:00:00 AM | 8/5/2015 12:00:00 AM | 8/5/2015 2:03 PM |
| Details | Last Recertification Date | Update | | 8/30/2013 12:00:00 AM | 9/4/2014 12:00:00 AM | 9/4/2014 11:55 AM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 8/30/2013 12:00:00 AM | 8/30/2013 12:55 PM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 5/9/2012 8:45 AM |
| Details | Last Recertification Date | Insert | | | | 9/30/2010 8:22 AM |
| Details | Grant Number | Insert | | | | 9/30/2010 8:22 AM |
| Details | 340B ID | Insert | | | SCH360197-00 | 9/30/2010 8:22 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 9/30/2010 8:22 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 9/30/2010 8:22 AM |
| Details | Medicare Provider Number | Insert | | | 360197 | 9/30/2010 8:22 AM |
| Details | Entity Name | Insert | | | MARY RUTAN HOSPITAL | 9/30/2010 8:22 AM |
| Details | Program Code | Insert | | | SCH | 9/30/2010 8:22 AM |
| Details | Entity Subname | Insert | | | | 9/30/2010 8:22 AM |
| Dates | Participating Approval Date | Insert | | | 9/27/2010 12:00:00 AM | 9/30/2010 8:22 AM |
| Details | State | Insert | | | Active | 9/30/2010 8:22 AM |
| Dates | Registration Date | Insert | | | 9/27/2010 12:00:00 AM | 9/30/2010 8:22 AM |
| Dates | Signed By Date | Insert | | | 9/27/2010 12:00:00 AM | 9/30/2010 8:22 AM |
| Dates | Start Date | Insert | | | 9/30/2010 12:00:00 AM | 9/30/2010 8:22 AM |
| Terminations | Termination Comments | Insert | | | | 9/30/2010 8:22 AM |
| Terminations | Termination Date | Insert | | | | 9/30/2010 8:22 AM |
| Terminations | Termination Effective Date | Insert | | | | 9/30/2010 8:22 AM |
| Terminations | Termination Reason | Insert | | | | 9/30/2010 8:22 AM |
| Details | Comments Public | Insert | | | 9/28/2010 - DOC RECEIVED TO CONFIRM ELIG DSH ADJ % | 9/30/2010 8:22 AM |