Covered Entity Details

SCH230081-00 Munson Healthcare Cadillac Hospital (Terminated) - information as of 5/1/2025 11:46:41 PM

Main Details

Name

Munson Healthcare Cadillac Hospital

Subdivision Name

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH230081-00

Medicare Provider Number

230081

Additional Details

Current Program Status

Terminated

Registration Date

5/30/2012

Participating Start Date

7/1/2012

Participating Approval Date

6/18/2012

Last Recertification Date

8/19/2021

Termination Date
Termination Reason

4/1/2022
Change of covered entity type

Contacts

Authorizing Official

Munson Healthcare
Alicia Maitland, CFO
(231) 935-7840

Primary Contact

Munson Healthcare
Sam Patrick Niemi, System Director Reimbursement
(231) 935-7761

Addresses

Street Address

400 Hobart St
Cadillac, MI 49601

Billing Address

Northern Michigan Supply Alliance
Munson Healthcare Cadillac Hospital
PO Box 669
Traverse City, MI 49685

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?
No

Shipping Addresses

Shipping Address 1

Munson Healthcare Cadillac Hospital
850 Lester Street
Cadillac, MI 49601

Shipping Address 2

Munson Healthcare Cadillac Hospital
400 Hobart Street
Cadillac, MI 49601

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	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/24/2019	07/01/2019	04/01/2022	04/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/24/2019	07/01/2019	04/01/2022	04/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/24/2019	07/01/2019	04/01/2022	04/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/24/2019	07/01/2019	04/01/2022	04/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/24/2019	07/01/2019	04/01/2022	04/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/24/2019	07/01/2019	04/01/2022	04/01/2022
Contract Detail	CADILLAC FAMILY PHARMACY, LLC	108 N MITCHELL ST		CADILLAC	MI	49601-2713	10/22/2018	01/01/2019	04/01/2022	04/01/2022
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/22/2018	01/01/2019	04/01/2022	04/01/2022
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	G3320 BEECHER RD		FLINT	MI	48532-3614	10/22/2018	01/01/2019	12/31/2019	12/31/2019
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/10/2019	10/01/2019	04/01/2022	04/01/2022
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/10/2019	10/01/2019	04/01/2022	04/01/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/10/2019	10/01/2019	04/01/2022	04/01/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/10/2019	10/01/2019	04/01/2022	04/01/2022
Contract Detail	FAMILY FARE	FAMILY FARE PHARMACY #648	602 S MITCHELL ST	CADILLAC	MI	49601	01/14/2019	04/01/2019	04/01/2022	04/01/2022
Contract Detail	FAMILY FARE PHARMACY 114	1550 GEZON PKWY SW STE E101		WYOMING	MI	49509	01/14/2019	04/01/2019	12/31/2019	01/06/2020
Contract Detail	KRONNER PHARMACY INC	778 W HOUGHTON LAKE DR	PO BOX 116	PRUDENVILLE	MI	48651	10/22/2018	01/01/2019	12/31/2019	01/06/2020
Contract Detail	LC FAMILY PHARMACY	57 N MOREY RD		LAKE CITY	MI	49651	10/17/2019	01/01/2020	04/01/2022	04/01/2022
Contract Detail	MCBAIN FAMILY PHARMACY	119 N ROLAND ST		MC BAIN	MI	49657	04/24/2019	07/01/2019	04/01/2022	04/01/2022
Contract Detail	MEIJER DISTRIBUTION INC #90	2721 WALKER AVE NW		GRAND RAPIDS	MI	49544	04/12/2018	07/01/2018	04/01/2022	04/01/2022
Contract Detail	MEIJER INC #171	8605 EAST 34 ROAD		CADILLAC	MI	49601	04/12/2018	07/01/2018	04/01/2022	04/01/2022
Contract Detail	MEIJER PHARMACY #464	41255 COCA COLA DR.		BELLEVILLE	MI	48111-1827	04/12/2018	07/01/2018	04/01/2022	04/01/2022
Contract Detail	MEIJER STORES LIMITED PARTNERSHIP	D/B/A MEIJER PHARMACY #463	1515 PROFIT DR.	FORT WAYNE	IN	46808	04/12/2018	07/01/2018	04/01/2022	04/01/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/17/2020	07/01/2020	04/01/2022	04/01/2022
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/17/2020	07/01/2020	04/01/2022	04/01/2022
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4506	720 SOUTH MITCHELL STREET	CADILLAC	MI	49601	10/24/2014	01/01/2015	04/01/2022	04/01/2022
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/17/2019	01/01/2020	04/01/2022	04/01/2022
Contract Detail	WAL-MART PHARMACY 10-1432	8917 EAST 34 ROAD		CADILLAC	MI	49601	10/23/2014	01/01/2015	04/01/2022	04/01/2022
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/17/2019	01/01/2020	04/01/2022	04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07660	1220 N MITCHELL	CADILLAC	MI	49601-1261	07/16/2014	10/01/2014	04/01/2022	04/01/2022
Contract Detail	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	07/31/2014	10/01/2014	07/01/2015	07/07/2015
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/31/2014	10/01/2014	07/01/2015	07/07/2015
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/15/2021	10/01/2021	04/01/2022	04/01/2022

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
SCH230081-01	Child	SCH	Munson Healthcare Cadillac Hospital	Cadillac Primary Care and OB/GYN	7985 Mackinaw Trail	Cadillac	MI	Terminated
SCH230081-02	Child	SCH	Munson Healthcare Cadillac Hospital	McBain Family Practice	100 N ROLAND ST	MCBAIN	MI	Terminated
SCH230081-03	Child	SCH	Munson Healthcare Cadillac Hospital	MUNSON HEALTHCARE CADILLAC - Urgent Care	302 HOBART ST	CADILLAC	MI	Terminated
SCH230081-04	Child	SCH	Munson Healthcare Cadillac Hospital	MUNSON HEALTHCARE CADILLAC - Primary Care	100 N ROLAND ST	MCBAIN	MI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Niemi, Sam Patrick Manager Reimbursement Munson Healthcare 2319357761	Niemi, Sam Patrick System Director Reimbursement Munson Healthcare 2319357761	5/2/2022 12:31 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	2/23/2022 12:56 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	2/23/2022 12:56 PM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	2/23/2022 12:56 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	2/23/2022 12:56 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	2/23/2022 12:56 PM
Details	Last Recertification Date	Update	Recertification	8/26/2020 12:09:34 PM	8/19/2021 10:24:28 AM	8/19/2021 10:24 AM
Contacts	Authorizing Official	Update	AO Change Request	Hepler, Mark CFO Munson Healthcare 2319356702	Maitland, Alicia CFO Munson Healthcare 2319357840	6/23/2021 11:58 AM
Contacts	Primary Contact	Update	Change Request	Leach, Steve Regional Director, Reimbursement Munson Healthcare 2319357797	Niemi, Sam Patrick Manager Reimbursement Munson Healthcare 2319357761	10/28/2020 7:58 AM
Details	Last Recertification Date	Update	Recertification	9/15/2019 2:46:21 PM	8/26/2020 12:09:34 PM	8/26/2020 12:09 PM
Details	Last Recertification Date	Update	Recertification	8/28/2018 11:48:23 AM	9/15/2019 2:46:21 PM	9/15/2019 2:46 PM
Details	Last Recertification Date	Update	Recertification	12/1/2017 3:38:48 PM	8/28/2018 11:48:23 AM	8/28/2018 11:48 AM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	12/1/2017 3:38:48 PM	12/1/2017 3:38 PM
Contacts	Authorizing Official	Update		Hepler, Mark CFO 2319356702	Hepler, Mark CFO Munson Healthcare 2319356702	10/4/2017 10:05 AM
Contacts	Primary Contact	Update		Leach, Steve Regional Director, Reimbursement 2319357797	Leach, Steve Regional Director, Reimbursement Munson Healthcare 2319357797	10/2/2017 3:45 PM
Contacts	Authorizing Official	Update		Ellis, Kristin Director of Finance 2318767808	Hepler, Mark CFO 2319356702	8/10/2017 8:38 AM
Contacts	Primary Contact	Update		Ellis, Kristin Director of Finance 2318767808	Leach, Steve Regional Director, Reimbursement 2319357797	7/27/2017 3:25 PM
Contacts	Signed By	Insert			Boyer, David A. CFO 2318767401	7/27/2017 3:25 PM
Addresses	Main Address	Insert			400 Hobart St Cadillac, MI 49601	7/27/2017 3:24 PM
Addresses	Billing Address	Insert			Northern Michigan Supply Alliance Munson Healthcare Cadillac Hospital PO Box 669 Traverse City, MI 49685	7/27/2017 3:24 PM
Addresses	Shipping Address	Insert			Munson Healthcare Cadillac Hospital 400 Hobart Street Cadillac, MI 49601	7/27/2017 3:24 PM
Addresses	Shipping Address	Insert			Munson Healthcare Cadillac Hospital 850 Lester Street Cadillac, MI 49601	7/27/2017 3:24 PM
Contacts	Authorizing Official	Insert			Ellis, Kristin Director of Finance 2318767808	4/3/2017 10:51 AM
Contacts	Primary Contact	Update		Ellis, Kristin Director of Finance 2318767808	Ellis, Kristin Director of Finance 2318767808	4/3/2017 10:51 AM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 6:51 AM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/24/2015 12:00:00 AM	8/24/2015 11:22 AM
Contacts	Primary Contact	Insert			Ellis, Kristin Director of Finance 2318767808	1/30/2015 3:15 PM
Details	Entity Name	Update		Mercy Hospital Cadillac	Munson Healthcare Cadillac Hospital	1/30/2015 3:15 PM
Details	Last Recertification Date	Update		8/28/2013 12:00:00 AM	8/7/2014 12:00:00 AM	8/7/2014 10:57 AM
Details	Last Recertification Date	Update			8/28/2013 12:00:00 AM	8/28/2013 6:50 AM
Details	340B ID	Update		IS-DM-SCH230081-00	SCH230081-00	6/18/2012 1:35 PM
Dates	Participating Approval Date	Update			6/18/2012 12:00:00 AM	6/18/2012 1:35 PM
Details	State	Update		Pending	Active	6/18/2012 1:35 PM
Dates	Start Date	Update			7/1/2012 12:00:00 AM	6/18/2012 1:35 PM
Details	340B ID	Update		DM-060112F	IS-DM-SCH230081-00	6/11/2012 10:20 AM
Details	340B ID	Update		DM053112C	DM-060112F	6/1/2012 2:17 PM
Details	340B ID	Update		ONLINE_REG	DM053112C	5/30/2012 10:47 PM
Details	Last Recertification Date	Insert				5/30/2012 12:19 PM
Details	Grant Number	Insert				5/30/2012 12:19 PM
Details	340B ID	Insert			ONLINE_REG	5/30/2012 12:19 PM
Details	Is Authorizing Official EHB Data	Insert				5/30/2012 12:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert				5/30/2012 12:19 PM
Details	Medicare Provider Number	Insert			230081	5/30/2012 12:19 PM
Details	Entity Name	Insert			Mercy Hospital Cadillac	5/30/2012 12:19 PM
Details	Program Code	Insert			SCH	5/30/2012 12:19 PM
Details	Entity Subname	Insert				5/30/2012 12:19 PM
Dates	Participating Approval Date	Insert				5/30/2012 12:19 PM
Details	State	Insert			Pending	5/30/2012 12:19 PM
Dates	Registration Date	Insert			5/30/2012 12:00:00 AM	5/30/2012 12:19 PM
Dates	Signed By Date	Insert			5/30/2012 12:00:00 AM	5/30/2012 12:19 PM
Dates	Start Date	Insert				5/30/2012 12:19 PM
Terminations	Termination Comments	Insert				5/30/2012 12:19 PM
Terminations	Termination Date	Insert				5/30/2012 12:19 PM
Terminations	Termination Effective Date	Insert				5/30/2012 12:19 PM
Terminations	Termination Reason	Insert				5/30/2012 12:19 PM