Covered Entity Details

CAH141335-00 Mercy Harvard Hospital, Inc (Active) - information as of 6/24/2025 12:04:11 AM

Main Details

Name

Mercy Harvard Hospital, Inc

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141335-00

Medicare Provider Number

141335

Additional Details

Current Program Status

Active

Registration Date

10/14/2013

Participating Start Date

1/1/2014

Participating Approval Date

11/7/2013

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Mercy Health
Shannon Dunphy-Alexander, Senior Vice President / CFO
(608) 757-3126

Primary Contact

Mercyhealth
Clark Montgomery, System Manager of Pharmacy Business and 340B Program
(406) 698-8719

Addresses

Street Address

901 Grant Street
Harvard, IL 60033-1821

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
WI	11002000	1427001445
IL	311551871,8005	1427001445

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	04/17/2017	07/01/2017		07/01/2017	11/21/2017

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
No records to display.

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Montgomery, Clark Pharmacy 340B Manager Mercyhealth 4066988719	Montgomery, Clark System Manager of Pharmacy Business and 340B Program Mercyhealth 4066988719	2/27/2025 12:55 PM
Contacts	Authorizing Official	Update	Change Request	Anderson, Todd Vice President Finance Mercyhealth 8159716738	Dunphy-Alexander, Shannon Senior Vice President / CFO Mercy Health 6087573126	1/13/2025 9:50 AM
Details	Last Recertification Date	Update	Recertification	8/26/2023 12:08:31 PM	8/29/2024 11:23:48 AM	8/29/2024 11:23 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 5:54:59 PM	8/26/2023 12:08:31 PM	8/26/2023 12:08 PM
Contacts	Primary Contact	Update	Change Request	Carlson, Kyle Manager of Pharmacy 340B Program Mercyhealth 8159716216	Montgomery, Clark Pharmacy 340B Manager Mercyhealth 4066988719	4/10/2023 10:59 AM
Addresses	Shipping Address	Delete	Change Request	Mercy Woodstock Pharmacy 2000 Lake Ave Woodstock, IL 60098		3/2/2023 12:37 PM
Contacts	Primary Contact	Update	Profile Change Request	Carlson, Kyle 340B Program Coordinator MercyHealth 8159716216	Carlson, Kyle Manager of Pharmacy 340B Program Mercyhealth 8159716216	9/1/2022 12:43 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 8:45:49 AM	8/30/2022 5:54:59 PM	8/30/2022 5:54 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/24/2022 2:46 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		311551871	6/24/2022 2:46 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/24/2022 2:46 PM
Details	Last Recertification Date	Update	Recertification	9/8/2020 11:42:50 AM	8/16/2021 8:45:49 AM	8/16/2021 8:45 AM
Contacts	Authorizing Official	Update	Change Request	Dunphy-Alexander, Shannon Senior Vice President / CFO Mercy Health 6087573126	Anderson, Todd Vice President Finance Mercyhealth 8159716738	3/4/2021 2:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1427001445	9/8/2020 11:42 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/8/2020 11:42 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1427001445	9/8/2020 11:42 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/8/2020 11:42 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1427001445 ( )		9/8/2020 11:42 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 6:54:27 AM	9/8/2020 11:42:50 AM	9/8/2020 11:42 AM
Contacts	Primary Contact	Update	Change Request	Gee, Katie Business Coordinator Mercyhealth 8159712394	Carlson, Kyle 340B Program Coordinator MercyHealth 8159716216	8/17/2020 8:00 AM
Details	Last Recertification Date	Update	Recertification	8/30/2018 12:42:07 PM	8/26/2019 6:54:27 AM	8/26/2019 6:54 AM
Contacts	Authorizing Official	Update	Change Request	Cook, John Senior VP / CFO Mercyhealth 6087566642	Dunphy-Alexander, Shannon Senior Vice President / CFO Mercy Health 6087573126	7/1/2019 8:56 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/26/2019 5:34 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11002000	2/26/2019 5:34 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	2/26/2019 5:34 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 7:53:17 AM	8/30/2018 12:42:07 PM	8/30/2018 12:42 PM
Details	Last Recertification Date	Update	Recertification	8/25/2016 12:00:00 AM	11/15/2017 7:53:17 AM	11/15/2017 7:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/9/2017 9:30 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		8005	10/9/2017 9:30 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/9/2017 9:30 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1427001445	10/9/2017 9:30 AM
Contacts	Authorizing Official	Update		Cook, John Senior VP / CFO 6087566642	Cook, John Senior VP / CFO Mercyhealth 6087566642	9/26/2017 5:06 PM
Contacts	Primary Contact	Update		Gee, Katie Business Coordinator 8159712394	Gee, Katie Business Coordinator Mercyhealth 8159712394	9/26/2017 4:35 PM
Contacts	Signed By	Insert			Cook, John Senior Vice President / CFO 6087566642	8/14/2017 3:51 PM
Addresses	Main Address	Insert			901 Grant Street Harvard, IL 60033-1821	8/7/2017 5:15 PM
Addresses	Shipping Address	Insert			Mercy Woodstock Pharmacy 2000 Lake Ave Woodstock, IL 60098	8/7/2017 5:15 PM
Contacts	Authorizing Official	Update		Dunphy-Alexander, Shannon Finance Director 6087573126	Cook, John Senior VP / CFO 6087566642	8/7/2017 5:15 PM
Contacts	Primary Contact	Update		Janczak, Don Director 6087566664	Gee, Katie Business Coordinator 8159712394	8/7/2017 5:15 PM
Contacts	Primary Contact	Insert			Janczak, Don Director 6087566664	5/23/2017 11:50 AM
Contacts	Authorizing Official	Insert			Dunphy-Alexander, Shannon Finance Director 6087573126	4/17/2017 11:22 AM
Details	Last Recertification Date	Update		8/26/2015 12:00:00 AM	8/25/2016 12:00:00 AM	8/25/2016 8:44 AM
Details	Last Recertification Date	Update		8/12/2014 12:00:00 AM	8/26/2015 12:00:00 AM	8/27/2015 10:00 AM
Details	Last Recertification Date	Update			8/12/2014 12:00:00 AM	8/12/2014 10:57 AM
Dates	Participating Approval Date	Update			11/7/2013 12:00:00 AM	11/7/2013 5:55 PM
Details	State	Update		Pending	Active	11/7/2013 5:55 PM
Dates	Start Date	Update			1/1/2014 12:00:00 AM	11/7/2013 5:55 PM
Details	340B ID	Update		Fabrine's????	CAH141335-00	11/4/2013 3:01 PM
Details	340B ID	Update		ONLINE_REG	Fabrine's????	11/4/2013 1:16 PM
Details	Last Recertification Date	Insert				10/14/2013 10:58 AM
Details	Grant Number	Insert				10/14/2013 10:58 AM
Details	340B ID	Insert			ONLINE_REG	10/14/2013 10:58 AM
Details	Is Authorizing Official EHB Data	Insert				10/14/2013 10:58 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/14/2013 10:58 AM
Details	Medicare Provider Number	Insert			141335	10/14/2013 10:58 AM
Details	Entity Name	Insert			Mercy Harvard Hospital, Inc	10/14/2013 10:58 AM
Details	Program Code	Insert			CAH	10/14/2013 10:58 AM
Details	Entity Subname	Insert				10/14/2013 10:58 AM
Dates	Participating Approval Date	Insert				10/14/2013 10:58 AM
Details	State	Insert			Pending	10/14/2013 10:58 AM
Dates	Registration Date	Insert			10/14/2013 12:00:00 AM	10/14/2013 10:58 AM
Dates	Signed By Date	Insert			10/14/2013 12:00:00 AM	10/14/2013 10:58 AM
Dates	Start Date	Insert				10/14/2013 10:58 AM
Terminations	Termination Comments	Insert				10/14/2013 10:58 AM
Terminations	Termination Date	Insert				10/14/2013 10:58 AM
Terminations	Termination Effective Date	Insert				10/14/2013 10:58 AM
Terminations	Termination Reason	Insert				10/14/2013 10:58 AM