Covered Entity Details

CAH141301-00 Kirby Medical Center (Active) - information as of 5/12/2025 10:04:27 PM

Main Details

Name

Kirby Medical Center

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141301-00

Medicare Provider Number

141301

Additional Details

Current Program Status

Active

Registration Date

1/14/2013

Participating Start Date

4/1/2013

Participating Approval Date

3/5/2013

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Kirby Medical Center
Steven D. Tenhouse, Chief Executive Officer
(217) 762-2115 Ext: 1501

Primary Contact

Kirby Medical Center
Kimberly Alvis, Chief Financial Officer
(217) 762-1514

Addresses

Street Address

1000 Medical Center Drive
Monticello, IL 61856

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	370661215007	1730179847

Shipping Addresses

Shipping Address 1

Kirby Medical Center
1000 Medical Center Drive
Monticello, IL 61856

Shipping Address 2

Kirby Medical Center
1000 Medical Center Drive
Kirby RX#1
Suite 100
Monticello, IL 61856

Shipping Address 3

Kirby Medical Center
1402 N Market St
Kirby Rx #2
Monticello, IL 61856

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04409	1713 W. SPRINGFIELD	CHAMPAIGN	IL	61821	07/15/2013	10/01/2013		07/15/2013
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05545	225 E. ASH	DECATUR	IL	62526	10/16/2017	01/01/2018		10/16/2017
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05388	1311 N STATE ROUTE 48	DECATUR	IL	62526	10/04/2021	01/01/2022		01/01/2022
Contract Detail	DICKS PHARMACY		WOOD, BRUCE DENE 118 S. VINE	ARTHUR	IL	61911	01/12/2023	04/01/2023	04/01/2023	04/01/2023
Contract Detail	JAC STORES INC	104 E SOUTHLINE RD STE A	DBA SAV MOR PHARMACY	TUSCOLA	IL	61953-2079	04/11/2013	07/01/2013		04/11/2013
Contract Detail	JAC STORES INC	DBA SAV-MOR PHARMACY	100 E US HIGHWAY 36 STE B	ATWOOD	IL	61913	01/17/2017	04/01/2017		01/17/2017
Contract Detail	JAC STORES INC	DBA SAV MOR PHARMACY	407 S. JACKSON ST	CERRO GORDO	IL	61818	02/01/2018	04/01/2018		02/01/2018
Contract Detail	MONTICELLO DRUGS		109 W MAIN STREET	MONTICELLO	IL	61856	03/15/2013	04/01/2013	09/27/2016	09/27/2016
Contract Detail	REED PHARMACIES, LLC	DBA DICKS PHARMACY	122 S. WALNUT ST	ARTHUR	IL	61911	03/01/2023	04/01/2023		04/01/2023
Contract Detail	WALGREEN CO	DBA: WALGREENS #10800	424 W VAN BUREN ST	CLINTON	IL	61727-2130	04/05/2018	07/01/2018		04/05/2018
Contract Detail	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	04/18/2023	07/01/2023		07/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09921	1509 S NEIL ST	CHAMPAIGN	IL	61820	07/15/2013	10/01/2013		07/15/2013
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15166	108 N. MARKET STREET	MONTICELLO	IL	61856	07/15/2013	10/01/2013		07/15/2013
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12868	104 N LOMBARD ST	MAHOMET	IL	61853-9097	10/04/2016	01/01/2017		10/04/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05719	4995 E US ROUTE 36	DECATUR	IL	62521	10/16/2017	01/01/2018		10/16/2017
Contract Detail	WALGREEN CO.	DBA; WALGREENS #15169	1001 HEATHER DRIVE	MAHOMET	IL	61853	10/04/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15170	1701 CURTIS ROAD SUITE 1024	CHAMPAIGN	IL	61822	10/04/2021	01/01/2022	05/24/2022	05/24/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13921	420 W. FIRST DR.	DECATUR	IL	62521	10/04/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09852	302 E UNIVERSITY AVE	URBANA	IL	61802	10/04/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09792	625 W PERSHING RD	DECATUR	IL	62526	10/04/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09611	841 BLOOMINGTON RD	CHAMPAIGN	IL	61820	10/04/2021	01/01/2022	06/01/2022	02/04/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09851	2402 VILLAGE GREEN PLACE	CHAMPAIGN	IL	61822	10/04/2021	01/01/2022		01/01/2022
Contract Detail	WALGREEN CO.	1801 W WINDSOR RD STE 101		CHAMPAIGN	IL	61822-6217	01/13/2022	04/01/2022		04/01/2022
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/15/2013	10/01/2013	10/23/2017	10/23/2017
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/15/2021	10/01/2021		10/01/2021
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	07/15/2021	10/01/2021		10/01/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH141301-01	Child	CAH	Kirby Medical Center	Kirby Medical Group - Atwood	100 East US Highway 36	Atwood	IL	Active
CAH141301-02	Child	CAH	Kirby Medical Center	Kirby Medical Group - Monticello	1000 Medical Center Drive	Monticello	IL	Active
CAH141301-03	Child	CAH	Kirby Medical Center	Kirby Medical Group - Cerro Gordo - Cerro Gordo RHC	407 S. Jackson Street	Cerro Gordo	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 1:50:10 PM	8/20/2024 11:26:32 AM	8/20/2024 11:26 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 12:46:38 PM	8/15/2023 1:50:10 PM	8/15/2023 1:50 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 7:54:13 AM	8/24/2022 12:46:38 PM	8/24/2022 12:46 PM
Details	Last Recertification Date	Update	Recertification	8/18/2020 11:06:16 AM	8/17/2021 7:54:13 AM	8/17/2021 7:54 AM
Addresses	Shipping Address	Delete	Change Request	Kirby Medical Center 1000 Medical Center Drive Kirby RX Suite 100 Monticello, IL 61856		12/10/2020 3:51 PM
Addresses	Shipping Address	Insert	Change Request		Kirby Medical Center 1000 Medical Center Drive Kirby RX#1 Suite 100 Monticello, IL 61856	12/10/2020 3:51 PM
Addresses	Shipping Address	Insert	Change Request		Kirby Medical Center 1402 N Market St Kirby Rx #2 Monticello, IL 61856	12/10/2020 3:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/18/2020 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		370661215007	8/18/2020 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	8/18/2020 11:06 AM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/18/2020 11:06 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 6:53:14 AM	8/18/2020 11:06:16 AM	8/18/2020 11:06 AM
Addresses	Shipping Address	Insert	Change Request		Kirby Medical Center 1000 Medical Center Drive Monticello, IL 61856	12/4/2019 8:58 AM
Addresses	Shipping Address	Insert	Change Request		Kirby Medical Center 1000 Medical Center Drive Kirby RX Suite 100 Monticello, IL 61856	12/4/2019 8:58 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1730179847	8/26/2019 6:53 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 2:34:32 PM	8/26/2019 6:53:14 AM	8/26/2019 6:53 AM
Contacts	Primary Contact	Update	Recertification	Nazarian, Alexander CFO Kirby Medical Center 2177621514	Alvis, Kimberly Chief Financial Officer Kirby Medical Center 2177621514	8/16/2018 2:34 PM
Details	Last Recertification Date	Update	Recertification	11/5/2017 3:07:33 PM	8/16/2018 2:34:32 PM	8/16/2018 2:34 PM
Details	Last Recertification Date	Update	Recertification	10/26/2017 9:35:50 AM	11/5/2017 3:07:33 PM	11/5/2017 3:07 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	10/26/2017 9:35:50 AM	10/26/2017 9:35 AM
Contacts	Primary Contact	Insert	Change Request		Nazarian, Alexander CFO Kirby Medical Center 2177621514	10/16/2017 3:42 PM
Contacts	Authorizing Official	Update		Tenhouse, Steven D. Chief Executive Officer 2177622115-1501	Tenhouse, Steven D. Chief Executive Officer Kirby Medical Center 2177622115-1501	10/16/2017 3:15 PM
Contacts	Signed By	Update		Tenhouse, Steven D. Chief Executive Officer 2177622115-1501	Tenhouse, Steven D. Chief Executive Officer Kirby Medical Center 2177622115-1501	10/16/2017 3:15 PM
Contacts	Authorizing Official	Insert			Tenhouse, Steven D. Chief Executive Officer 2177622115-1501	1/17/2017 7:43 PM
Contacts	Signed By	Insert			Tenhouse, Steven D. Chief Executive Officer 2177622115-1501	1/17/2017 7:43 PM
Addresses	Main Address	Insert			1000 Medical Center Drive Monticello, IL 61856	8/10/2016 2:04 PM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 2:04 PM
Details	Last Recertification Date	Update		8/15/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 11:13 AM
Details	Last Recertification Date	Update		8/28/2013 12:00:00 AM	8/15/2014 12:00:00 AM	8/15/2014 4:04 PM
Details	Last Recertification Date	Update		8/28/2013 2:57:14 PM	8/28/2013 12:00:00 AM	3/7/2014 6:18 PM
Details	Last Recertification Date	Update			8/28/2013 2:57:14 PM	8/28/2013 2:57 PM
Details	340B ID	Update		ISJMCAH141301	CAH141301-00	3/5/2013 2:40 PM
Dates	Participating Approval Date	Update			3/5/2013 12:00:00 AM	3/5/2013 2:40 PM
Details	State	Update		Pending	Active	3/5/2013 2:40 PM
Dates	Start Date	Update			4/1/2013 12:00:00 AM	3/5/2013 2:40 PM
Details	340B ID	Update		JM011413G	ISJMCAH141301	2/20/2013 11:06 AM
Details	340B ID	Update		ONLINE_REG	JM011413G	1/15/2013 6:35 AM
Details	Last Recertification Date	Insert				1/14/2013 12:09 PM
Details	Grant Number	Insert				1/14/2013 12:09 PM
Details	340B ID	Insert			ONLINE_REG	1/14/2013 12:09 PM
Details	Is Authorizing Official EHB Data	Insert				1/14/2013 12:09 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/14/2013 12:09 PM
Details	Medicare Provider Number	Insert			141301	1/14/2013 12:09 PM
Details	Entity Name	Insert			Kirby Medical Center	1/14/2013 12:09 PM
Details	Program Code	Insert			CAH	1/14/2013 12:09 PM
Details	Entity Subname	Insert				1/14/2013 12:09 PM
Dates	Participating Approval Date	Insert				1/14/2013 12:09 PM
Details	State	Insert			Pending	1/14/2013 12:09 PM
Dates	Registration Date	Insert			1/14/2013 12:00:00 AM	1/14/2013 12:09 PM
Dates	Signed By Date	Insert			1/14/2013 12:00:00 AM	1/14/2013 12:09 PM
Dates	Start Date	Insert				1/14/2013 12:09 PM
Terminations	Termination Comments	Insert				1/14/2013 12:09 PM
Terminations	Termination Date	Insert				1/14/2013 12:09 PM
Terminations	Termination Effective Date	Insert				1/14/2013 12:09 PM
Terminations	Termination Reason	Insert				1/14/2013 12:09 PM