| Details | Last Recertification Date | Update | Recertification | 8/24/2023 9:22:00 AM | 9/3/2024 9:17:58 AM | 9/3/2024 9:17 AM |
| Contacts | Primary Contact | Update | Change Request | Salverson, Sandra
SVP Pharmacy Services
OSF HealthCare
3096248817 | krantz, amy
Manager Strategic Reimbursement
OSF Healthcare
3096552865 | 6/28/2024 2:35 PM |
| Contacts | Authorizing Official | Update | Change Request | McGrew, Diane L.
President
OSF Healthcare
3096552850 | Salverson, Sandra
SVP Pharmacy Services
OSF HealthCare
3096248817 | 6/27/2024 7:58 AM |
| Addresses | Main Address | Update | Recertification |
145 4th Avenue NE
Gladstone, MI 49837 |
145 4th Avenue N
Gladstone, MI 49837 | 8/24/2023 9:22 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 8:03:59 AM | 8/24/2023 9:22:00 AM | 8/24/2023 9:22 AM |
| Contacts | Primary Contact | Update | Group Change Request | Storm, Jerry
Senior Vice President of Pharmacy Services
OSF Healthcare
3096553489 | Salverson, Sandra
SVP Pharmacy Services
OSF HealthCare
3096248817 | 4/26/2023 9:53 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2021 10:45:26 AM | 9/8/2022 8:03:59 AM | 9/8/2022 8:03 AM |
| Details | Entity Subname | Update | Recertification | OSF St. Francis Hospital Medical Group-Gladstone (RHC) | OSF Healthcare St. Francis Hospital & Medical Group-Gladstone | 9/8/2022 8:03 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | McGrew, Diane Marie
President
OSF Healthcare
3096552850 | McGrew, Diane L.
President
OSF Healthcare
3096552850 | 4/11/2022 5:02 PM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2020 11:03:02 AM | 8/30/2021 10:45:26 AM | 8/30/2021 10:45 AM |
| Details | Last Recertification Date | Update | Recertification | 9/5/2019 9:02:12 AM | 8/27/2020 11:03:02 AM | 8/27/2020 11:03 AM |
| Details | Last Recertification Date | Update | Recertification | 8/15/2018 3:04:40 PM | 9/5/2019 9:02:12 AM | 9/5/2019 9:02 AM |
| Addresses | Main Address | Update | Change Request |
128 Michigan
Gladstone, MI 49837 |
145 4th Avenue NE
Gladstone, MI 49837 | 1/3/2019 11:00 AM |
| Details | Last Recertification Date | Update | Recertification | 12/6/2017 12:51:25 PM | 8/15/2018 3:04:40 PM | 8/15/2018 3:04 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2016 12:00:00 AM | 12/6/2017 12:51:25 PM | 12/6/2017 12:51 PM |
| Contacts | Authorizing Official | Update | AO Change Request | McGrew, Diane Marie
President
3096552850 | McGrew, Diane Marie
President
OSF Healthcare
3096552850 | 12/6/2017 12:45 PM |
| Contacts | Primary Contact | Update | Recertification | Storm, Jerry
Senior Vice President of Pharmacy Services
3096553489 | Storm, Jerry
Senior Vice President of Pharmacy Services
OSF Healthcare
3096553489 | 11/29/2017 12:14 PM |
| Contacts | Primary Contact | Update | | Saathoff, Stephen
Manager, Strategic Reimbursement
3096554886 | Storm, Jerry
Senior Vice President of Pharmacy Services
3096553489 | 6/5/2017 1:04 PM |
| Contacts | Authorizing Official | Insert | | | McGrew, Diane Marie
President
3096552850 | 6/5/2017 1:04 PM |
| Contacts | Signed By | Insert | | | McGrew, Diane Marie
President
3096552850 | 6/5/2017 1:04 PM |
| Addresses | Main Address | Insert | | |
128 Michigan
Gladstone, MI 49837 | 8/16/2016 2:17 PM |
| Details | Last Recertification Date | Update | | 8/17/2015 12:00:00 AM | 8/16/2016 12:00:00 AM | 8/16/2016 2:17 PM |
| Contacts | Primary Contact | Insert | | | Saathoff, Stephen
Manager, Strategic Reimbursement
3096554886 | 4/14/2016 10:09 AM |
| Details | Last Recertification Date | Update | | 8/7/2014 12:00:00 AM | 8/17/2015 12:00:00 AM | 8/17/2015 5:06 PM |
| Details | Last Recertification Date | Update | | 9/3/2013 12:00:00 AM | 8/7/2014 12:00:00 AM | 8/7/2014 12:16 PM |
| Details | Last Recertification Date | Update | | 9/3/2013 11:21:49 AM | 9/3/2013 12:00:00 AM | 7/1/2014 7:27 AM |
| Details | Last Recertification Date | Update | | | 9/3/2013 11:21:49 AM | 9/3/2013 11:21 AM |
| Details | 340B ID | Update | | IS-JM-CAH231337-02 | CAH231337-02 | 10/25/2012 10:40 AM |
| Dates | Participating Approval Date | Update | | | 10/25/2012 12:00:00 AM | 10/25/2012 10:40 AM |
| Details | State | Update | | Pending | Active | 10/25/2012 10:40 AM |
| Dates | Start Date | Update | | | 1/1/2013 12:00:00 AM | 10/25/2012 10:40 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | IS-JM-CAH231337-02 | 10/24/2012 1:58 PM |
| Details | Last Recertification Date | Insert | | | | 10/12/2012 10:04 AM |
| Details | Grant Number | Insert | | | | 10/12/2012 10:04 AM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 10/12/2012 10:04 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/12/2012 10:04 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/12/2012 10:04 AM |
| Details | Medicare Provider Number | Insert | | | 231337 | 10/12/2012 10:04 AM |
| Details | Entity Name | Insert | | | St Francis Hospital | 10/12/2012 10:04 AM |
| Details | Program Code | Insert | | | CAH | 10/12/2012 10:04 AM |
| Details | Entity Subname | Insert | | | OSF St. Francis Hospital Medical Group-Gladstone (RHC) | 10/12/2012 10:04 AM |
| Dates | Participating Approval Date | Insert | | | | 10/12/2012 10:04 AM |
| Details | State | Insert | | | Pending | 10/12/2012 10:04 AM |
| Dates | Registration Date | Insert | | | 10/12/2012 12:00:00 AM | 10/12/2012 10:04 AM |
| Dates | Signed By Date | Insert | | | 10/12/2012 12:00:00 AM | 10/12/2012 10:04 AM |
| Dates | Start Date | Insert | | | | 10/12/2012 10:04 AM |
| Terminations | Termination Comments | Insert | | | | 10/12/2012 10:04 AM |
| Terminations | Termination Date | Insert | | | | 10/12/2012 10:04 AM |
| Terminations | Termination Effective Date | Insert | | | | 10/12/2012 10:04 AM |
| Terminations | Termination Reason | Insert | | | | 10/12/2012 10:04 AM |