| Details | State | Update | | To Be Terminated | Terminated | 10/1/2024 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | | 10/1/2024 12:00:00 AM | 7/22/2024 1:09 PM |
| Details | State | Update | Hospital Type Change Request | Active | To Be Terminated | 7/22/2024 1:09 PM |
| Terminations | Termination Date | Update | Hospital Type Change Request | | 10/1/2024 12:00:00 AM | 7/22/2024 1:09 PM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | | 10/1/2024 12:00:00 AM | 7/22/2024 1:09 PM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | | Change of covered entity type | 7/22/2024 1:09 PM |
| Contacts | Authorizing Official | Update | Change Request | Herron, Amy
Regional CFO
Franciscan Alliance
2198771033 | Kats, Justin
Division CFO - Crown Point & Michigan City
Franciscan Alliance
2197576403 | 7/1/2024 10:51 AM |
| Addresses | Shipping Address | Insert | Recertification | | Franciscan Health Michigan City Woodland Surgery Center
8865 W. 400 N., Suite 100
Michigan City, IN 46360 | 8/29/2023 9:03 PM |
| Addresses | Shipping Address | Insert | Recertification | | Franciscan Health Michigan City
3500 Franciscan Way
Michigan City, IN 46360 | 8/29/2023 9:03 PM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2022 11:14:35 AM | 8/29/2023 9:03:31 PM | 8/29/2023 9:03 PM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2021 11:37:12 AM | 8/30/2022 11:14:35 AM | 8/30/2022 11:14 AM |
| Contacts | Primary Contact | Update | Contract Pharmacy Change Request | Shondell, Laura
Administrative Director Medication Systems and Operations
Franciscan Alliance, Inc.
7654236900 | Shondell, Laura
Administrative Director Medication Systems and Operations
Franciscan Health
7654236900 | 4/11/2022 4:33 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Shondell, Laura
Administrative Director Medication Systems and Operations
Franciscan Health
7654236900 | Shondell, Laura
Administrative Director Medication Systems and Operations
Franciscan Alliance, Inc.
7654236900 | 4/11/2022 6:44 AM |
| Contacts | Authorizing Official | Update | Change Request | Cassara, Pamela
Chief Financial Officer
Franciscan Health
2198771033 | Herron, Amy
Regional CFO
Franciscan Alliance
2198771033 | 9/13/2021 4:29 PM |
| Addresses | Billing Address | Update | Recertification | Franciscan St. Anthony Health
301 W. Homer St.
Michigan City, IN 46360 | Franciscan Health Michigan City
3500 Franciscan Way
Michigan City, IN 46360 | 8/17/2021 11:37 AM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2020 9:43:33 AM | 8/17/2021 11:37:12 AM | 8/17/2021 11:37 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1710051941 | 9/2/2020 9:43 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | IN | 9/2/2020 9:43 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1710051941 ( ) | | 9/2/2020 9:43 AM |
| Details | Last Recertification Date | Update | Recertification | | 9/2/2020 9:43:33 AM | 9/2/2020 9:43 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Shondell, Laura
Administrative Director of Pharmacy Services
Franciscan Health
7655024514 | Shondell, Laura
Administrative Director Medication Systems and Operations
Franciscan Health
7654236900 | 8/30/2020 1:53 PM |
| Contacts | Authorizing Official | Update | Change Request | Weber, Trish L.
VP Operations/CNO
Franciscan Health Michigan City
2198771766 | Cassara, Pamela
Chief Financial Officer
Franciscan Health
2198771033 | 8/28/2020 10:44 AM |
| Contacts | Primary Contact | Update | Change Request | Mumaugh, Bryan J
Administrative Director of Pharmacy
Franciscan Alliance
2194076655 | Shondell, Laura
Administrative Director of Pharmacy Services
Franciscan Health
7655024514 | 1/7/2020 9:29 AM |
| Details | State | Update | | Approved | Active | 10/1/2019 12:04 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Mumaugh, Bryan J
Administrative Director of Pharmacy
Franciscan Alliance
2199322300-34212 | Mumaugh, Bryan J
Administrative Director of Pharmacy
Franciscan Alliance
2194076655 | 9/5/2019 3:46 PM |
| Addresses | Billing Address | Insert | Reinstatement | | Franciscan St. Anthony Health
301 W. Homer St.
Michigan City, IN 46360 | 9/5/2019 1:40 PM |
| Contacts | Signed By | Update | Reinstatement | Callaghan III, James T.
President
2198771410 | Weber, Trish L.
VP Operations/CNO
Franciscan Health Michigan City
2198771766 | 9/5/2019 1:40 PM |
| Contacts | Primary Contact | Update | Reinstatement | Harber, Eugene
Corporate Pharmacy Manager, 340b Operations
Franciscan Alliance
2199322300-35561 | Mumaugh, Bryan J
Administrative Director of Pharmacy
Franciscan Alliance
2199322300-34212 | 9/5/2019 1:40 PM |
| Dates | Participating Approval Date | Update | Reinstatement | | 9/5/2019 1:40:29 PM | 9/5/2019 1:40 PM |
| Details | State | Update | Reinstatement | Pending | Approved | 9/5/2019 1:40 PM |
| Dates | Signed By Date | Update | Reinstatement | 9/7/2012 12:00:00 AM | 7/12/2019 4:51:41 PM | 9/5/2019 1:40 PM |
| Dates | Start Date | Update | Reinstatement | | 10/1/2019 12:00:00 AM | 9/5/2019 1:40 PM |
| Details | Comments Public | Insert | Reinstatement | | Participated starting 1/1/2013; Terminated 1/1/2019; Reinstated 10/1/2019. | 9/5/2019 7:32 AM |
| Details | Last Recertification Date | Update | Reinstatement | 8/21/2018 10:41:26 AM | | 7/12/2019 4:31 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 1/1/2019 12:00:00 AM | | 7/12/2019 4:31 PM |
| Dates | Participating Approval Date | Update | Reinstatement | 10/9/2012 12:00:00 AM | | 7/12/2019 4:31 PM |
| Details | State | Update | Reinstatement | Terminated | Pending | 7/12/2019 4:31 PM |
| Dates | Registration Date | Update | Reinstatement | 9/7/2012 12:00:00 AM | 7/12/2019 4:31:02 PM | 7/12/2019 4:31 PM |
| Dates | Start Date | Update | Reinstatement | 1/1/2013 12:00:00 AM | | 7/12/2019 4:31 PM |
| Terminations | Termination Date | Update | Reinstatement | 1/1/2019 12:00:00 AM | | 7/12/2019 4:31 PM |
| Terminations | Termination Effective Date | Update | Reinstatement | 1/1/2019 12:00:00 AM | | 7/12/2019 4:31 PM |
| Terminations | Termination Reason | Update | Reinstatement | Change of covered entity type | | 7/12/2019 4:31 PM |
| Details | Last Recertification Date | Update | | | 8/21/2018 10:41:26 AM | 7/12/2019 4:03 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 1/1/2019 12:00:00 AM | 7/12/2019 4:03 PM |
| Dates | Participating Approval Date | Update | | | 10/9/2012 12:00:00 AM | 7/12/2019 4:03 PM |
| Details | State | Update | | Pending | Terminated | 7/12/2019 4:03 PM |
| Dates | Registration Date | Update | | 7/10/2019 5:23:25 PM | 9/7/2012 12:00:00 AM | 7/12/2019 4:03 PM |
| Dates | Start Date | Update | | | 1/1/2013 12:00:00 AM | 7/12/2019 4:03 PM |
| Terminations | Termination Date | Update | | | 1/1/2019 12:00:00 AM | 7/12/2019 4:03 PM |
| Terminations | Termination Effective Date | Update | | | 1/1/2019 12:00:00 AM | 7/12/2019 4:03 PM |
| Terminations | Termination Reason | Update | | | Change of covered entity type | 7/12/2019 4:03 PM |
| Details | Last Recertification Date | Update | | 8/21/2018 10:41:26 AM | | 7/10/2019 5:23 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | 1/1/2019 12:00:00 AM | | 7/10/2019 5:23 PM |
| Dates | Participating Approval Date | Update | | 10/9/2012 12:00:00 AM | | 7/10/2019 5:23 PM |
| Details | State | Update | | Terminated | Pending | 7/10/2019 5:23 PM |
| Dates | Registration Date | Update | | 9/7/2012 12:00:00 AM | 7/10/2019 5:23:25 PM | 7/10/2019 5:23 PM |
| Dates | Start Date | Update | | 1/1/2013 12:00:00 AM | | 7/10/2019 5:23 PM |
| Terminations | Termination Date | Update | | 1/1/2019 12:00:00 AM | | 7/10/2019 5:23 PM |
| Terminations | Termination Effective Date | Update | | 1/1/2019 12:00:00 AM | | 7/10/2019 5:23 PM |
| Terminations | Termination Reason | Update | | Change of covered entity type | | 7/10/2019 5:23 PM |
| Details | State | Update | | To Be Terminated | Terminated | 1/1/2019 12:05 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Hospital Type Change Request | | 1/1/2019 12:00:00 AM | 10/25/2018 5:35 PM |
| Details | State | Update | Hospital Type Change Request | Active | To Be Terminated | 10/25/2018 5:35 PM |
| Terminations | Termination Date | Update | Hospital Type Change Request | | 1/1/2019 12:00:00 AM | 10/25/2018 5:35 PM |
| Terminations | Termination Effective Date | Update | Hospital Type Change Request | | 1/1/2019 12:00:00 AM | 10/25/2018 5:35 PM |
| Terminations | Termination Reason | Update | Hospital Type Change Request | | Change of covered entity type | 10/25/2018 5:35 PM |
| Contacts | Primary Contact | Update | Change Request | Olson, Michael
Director of Pharmacy
Franciscan Health Michigan City
2198771426 | Harber, Eugene
Corporate Pharmacy Manager, 340b Operations
Franciscan Alliance
2199322300-35561 | 9/5/2018 1:20 PM |
| Details | Last Recertification Date | Update | Recertification | 11/27/2017 1:09:31 PM | 8/21/2018 10:41:26 AM | 8/21/2018 10:41 AM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2016 12:00:00 AM | 11/27/2017 1:09:31 PM | 11/27/2017 1:09 PM |
| Contacts | Authorizing Official | Update | | Weber, Trish L.
VP Operations/CNO
2198771766 | Weber, Trish L.
VP Operations/CNO
Franciscan Health Michigan City
2198771766 | 10/25/2017 4:12 PM |
| Contacts | Primary Contact | Update | | Olson, Michael
Director of Pharmacy
2198771426 | Olson, Michael
Director of Pharmacy
Franciscan Health Michigan City
2198771426 | 9/18/2017 4:31 PM |
| Contacts | Primary Contact | Insert | | | Olson, Michael
Director of Pharmacy
2198771426 | 8/14/2017 11:28 AM |
| Contacts | Authorizing Official | Insert | | | Weber, Trish L.
VP Operations/CNO
2198771766 | 8/14/2017 11:28 AM |
| Addresses | Main Address | Insert | | |
8865 W. 400 N., Suite 100
Michigan City, IN 46360 | 8/14/2017 11:22 AM |
| Addresses | Billing Address | Insert | | | Franciscan St. Anthony Health
301 W. Homer St.
Michigan City, IN 46360 | 8/14/2017 11:22 AM |
| Contacts | Signed By | Insert | | | Callaghan III, James T.
President
2198771410 | 8/14/2017 11:22 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 8/14/2017 11:21 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 100269360A | 8/14/2017 11:21 AM |
| Medicaid Billing | Medicaid: State | Insert | | | IN | 8/14/2017 11:21 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1710051941 | 8/14/2017 11:21 AM |
| Details | Entity Name | Update | | FRANCISCAN ST. ANTHONY HEALTH MICHIGAN CITY | FRANCISCAN HEALTH MICHIGAN CITY | 11/4/2016 3:06 PM |
| Details | Last Recertification Date | Update | | 8/25/2015 12:00:00 AM | 8/17/2016 12:00:00 AM | 8/17/2016 9:43 AM |
| Details | Last Recertification Date | Update | | 9/5/2014 12:00:00 AM | 8/25/2015 12:00:00 AM | 8/25/2015 6:40 AM |
| Details | Last Recertification Date | Update | | 9/13/2013 12:00:00 AM | 9/5/2014 12:00:00 AM | 9/5/2014 8:55 AM |
| Details | Last Recertification Date | Update | | | 9/13/2013 12:00:00 AM | 9/13/2013 10:18 AM |
| Details | 340B ID | Update | | ISJM?-RRC150015-01 | RRC150015-01 | 10/9/2012 1:37 PM |
| Dates | Participating Approval Date | Update | | | 10/9/2012 12:00:00 AM | 10/9/2012 1:37 PM |
| Details | State | Update | | Pending | Active | 10/9/2012 1:37 PM |
| Dates | Start Date | Update | | | 1/1/2013 12:00:00 AM | 10/9/2012 1:37 PM |
| Details | 340B ID | Update | | JM?-RRC150015-01 | ISJM?-RRC150015-01 | 10/4/2012 1:05 PM |
| Details | 340B ID | Update | | ISJMRRC150015-01 | JM?-RRC150015-01 | 10/3/2012 4:34 PM |
| Details | 340B ID | Update | | JM092612H | ISJMRRC150015-01 | 10/3/2012 3:55 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | JM092612H | 9/26/2012 10:16 PM |
| Details | Last Recertification Date | Insert | | | | 9/7/2012 11:01 AM |
| Details | Grant Number | Insert | | | | 9/7/2012 11:01 AM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 9/7/2012 11:01 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 9/7/2012 11:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 9/7/2012 11:01 AM |
| Details | Medicare Provider Number | Insert | | | 150015 | 9/7/2012 11:01 AM |
| Details | Entity Name | Insert | | | FRANCISCAN ST. ANTHONY HEALTH MICHIGAN CITY | 9/7/2012 11:01 AM |
| Details | Program Code | Insert | | | RRC | 9/7/2012 11:01 AM |
| Details | Entity Subname | Insert | | | Woodland Surgery Center | 9/7/2012 11:01 AM |
| Dates | Participating Approval Date | Insert | | | | 9/7/2012 11:01 AM |
| Details | State | Insert | | | Pending | 9/7/2012 11:01 AM |
| Dates | Registration Date | Insert | | | 9/7/2012 12:00:00 AM | 9/7/2012 11:01 AM |
| Dates | Signed By Date | Insert | | | 9/7/2012 12:00:00 AM | 9/7/2012 11:01 AM |
| Dates | Start Date | Insert | | | | 9/7/2012 11:01 AM |
| Terminations | Termination Comments | Insert | | | | 9/7/2012 11:01 AM |
| Terminations | Termination Date | Insert | | | | 9/7/2012 11:01 AM |
| Terminations | Termination Effective Date | Insert | | | | 9/7/2012 11:01 AM |
| Terminations | Termination Reason | Insert | | | | 9/7/2012 11:01 AM |