| Addresses | Shipping Address | Delete | Change Request | Ascension Rx
7701 Metropolis Drive
200C
Austin, TX 78744 | | 4/2/2025 8:17 AM |
| Contacts | Primary Contact | Update | Group Change Request | Hamdan, Nawal
340B Manager
Ascension
7084698918 | Hamdan, Nawal
340B Manager
Prime Healthcare - Illinois
7084698918 | 3/19/2025 1:17 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1467290809 | 3/16/2025 9:25 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | IL | 3/16/2025 9:25 AM |
| Contacts | Authorizing Official | Update | Change Request | Nocie, Joseph
CFO
Ascension
8159372430 | Chen, Sylvia
Regional VP - Pharmacy Services
Prime Healthcare - Illinois
6307763455 | 3/12/2025 3:42 PM |
| Contacts | Authorizing Official | Update | Change Request | Farr, Ronald
CFO
Ascension - Saint Alexius Medical Center
8474906901 | Nocie, Joseph
CFO
Ascension
8159372430 | 10/28/2024 10:15 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Farr, Ronald
CFO
Ascension - St Mary's Hospital - Kankakee
8159372430 | Farr, Ronald
CFO
Ascension - Saint Alexius Medical Center
8474906901 | 9/10/2024 10:37 AM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2023 1:48:41 PM | 8/15/2024 7:07:20 AM | 8/15/2024 7:07 AM |
| Contacts | Authorizing Official | Update | Change Request | Mulay, Michael James
Regional CFO - Chicago Metro Region
Ascension Health
7739908611 | Farr, Ronald
CFO
Ascension - St Mary's Hospital - Kankakee
8159372430 | 8/6/2024 7:49 AM |
| Addresses | Shipping Address | Insert | Change Request | | Ascension Rx
7701 Metropolis Drive
200C
Austin, TX 78744 | 3/5/2024 9:48 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 364195126042 (IL) | | 1/8/2024 9:55 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 364195126442 (IL) | | 1/8/2024 9:55 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 1/8/2024 9:55 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 36-4195126 | 1/8/2024 9:55 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | IL | 1/8/2024 9:55 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1336299544 (IL) | | 1/8/2024 9:55 AM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2022 3:49:40 PM | 8/22/2023 1:48:41 PM | 8/22/2023 1:48 PM |
| Contacts | Primary Contact | Update | Change Request | Fischer, Rick
340B Program Director
Ascension
6303097828 | Hamdan, Nawal
340B Manager
Ascension
7084698918 | 8/7/2023 7:49 AM |
| Contacts | Authorizing Official | Update | Change Request | Mulay, Michael James
CFO
AMITA Health Sts Mary - Kankakee
7739908611 | Mulay, Michael James
Regional CFO - Chicago Metro Region
Ascension Health
7739908611 | 10/31/2022 1:08 PM |
| Contacts | Primary Contact | Update | Group Change Request | Fischer, Rick
System Director, 340B
Amita Health
6303097828 | Fischer, Rick
340B Program Director
Ascension
6303097828 | 9/28/2022 10:03 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2021 4:52:30 PM | 8/31/2022 3:49:40 PM | 8/31/2022 3:49 PM |
| Contacts | Authorizing Official | Update | Change Request | Chen, Yuesha
Regional Chief Financial Officer
AMITA Health
8157417667 | Mulay, Michael James
CFO
AMITA Health Sts Mary - Kankakee
7739908611 | 3/10/2022 8:21 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Fischer, Rick
System Director, 340B
Amita Health
6309147828 | Fischer, Rick
System Director, 340B
Amita Health
6303097828 | 1/20/2022 2:41 PM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2020 9:17:48 AM | 8/24/2021 4:52:30 PM | 8/24/2021 4:52 PM |
| Addresses | Shipping Address | Delete | Change Request | Safecor Health
4060 Business Park Drive
Columbus, OH 43204 | | 5/18/2021 3:53 PM |
| Addresses | Billing Address | Update | Change Request | Saint Mary's Hospital
PO Box 33902
Indianapolis, IN 46203 | Ascension Health Ministry Service Center
PO Box 33902
Indianapolis, IN 46203 | 5/18/2021 3:53 PM |
| Addresses | Shipping Address | Insert | Change Request | | Safecor Health
4060 Business Park Drive
Columbus, OH 43204 | 4/12/2021 12:55 PM |
| Addresses | Billing Address | Insert | Change Request | | Saint Mary's Hospital
PO Box 33902
Indianapolis, IN 46203 | 1/18/2021 1:29 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | IL | 9/11/2020 9:17 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | IL | 9/11/2020 9:17 AM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2019 2:53:39 PM | 9/11/2020 9:17:48 AM | 9/11/2020 9:17 AM |
| Contacts | Authorizing Official | Update | Change Request | Lee-Such, Sun C
VP Pharmacy
Amita Health
2242732390 | Chen, Yuesha
Regional Chief Financial Officer
AMITA Health
8157417667 | 4/27/2020 4:42 PM |
| Contacts | Authorizing Official | Update | Change Request | Schimerowski, Deborah Ann
Regional CFO
Presence St. Mary's Hospital
8157257133-7667 | Lee-Such, Sun C
VP Pharmacy
Amita Health
2242732390 | 3/30/2020 8:10 AM |
| Contacts | Authorizing Official | Update | Change Request | Schimerowski, Deborah
Regional CFO
Presence Health
8157257133-7667 | Schimerowski, Deborah Ann
Regional CFO
Presence St. Mary's Hospital
8157257133-7667 | 12/19/2019 9:34 AM |
| Contacts | Primary Contact | Update | Change Request | Fischer, Rick
System Director, 340B
Presence Health
6309142872 | Fischer, Rick
System Director, 340B
Amita Health
6309147828 | 11/7/2019 1:34 PM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 11:24:35 AM | 9/2/2019 2:53:39 PM | 9/2/2019 2:53 PM |
| Contacts | Authorizing Official | Update | Change Request | Benner, David
System Vice President, Pharmacy and Laboratory Services
Presence Health
6309142842 | Schimerowski, Deborah
Regional CFO
Presence Health
8157257133-7667 | 9/26/2018 7:30 AM |
| Details | Last Recertification Date | Update | Recertification | 11/29/2017 3:02:12 PM | 8/22/2018 11:24:35 AM | 8/22/2018 11:24 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1215141627 ( ) | | 6/19/2018 11:17 AM |
| Details | Last Recertification Date | Update | Recertification | 8/15/2016 12:00:00 AM | 11/29/2017 3:02:12 PM | 11/29/2017 3:02 PM |
| Contacts | Authorizing Official | Insert | Change Request | | Benner, David
System Vice President, Pharmacy and Laboratory Services
Presence Health
6309142842 | 10/19/2017 4:16 PM |
| Contacts | Primary Contact | Update | Change Request | Janicek, Kimberly
Regional Directir of Pharmacy
8157417142 | Fischer, Rick
System Director, 340B
Presence Health
6309142872 | 10/13/2017 11:42 AM |
| Addresses | Main Address | Insert | | |
500 West Court Street
Kankakee, IL 60901 | 8/15/2016 7:48 PM |
| Contacts | Signed By | Insert | | | Lafine, Amy
CEO/Chief Nursing Officer
8159372401 | 8/15/2016 7:48 PM |
| Contacts | Primary Contact | Update | | Kuczero, Ken
pharmacy operations manager
8159372175 | Janicek, Kimberly
Regional Directir of Pharmacy
8157417142 | 8/15/2016 7:48 PM |
| Details | Last Recertification Date | Update | | 9/4/2015 12:00:00 AM | 8/15/2016 12:00:00 AM | 8/15/2016 7:48 PM |
| Details | Last Recertification Date | Update | | | 9/4/2015 12:00:00 AM | 9/4/2015 12:55 PM |
| Contacts | Primary Contact | Update | | Meyer, Emily
Regional Director of Pharmacy
8159372293 | Kuczero, Ken
pharmacy operations manager
8159372175 | 5/20/2015 7:24 AM |
| Contacts | Primary Contact | Insert | | | Meyer, Emily
Regional Director of Pharmacy
8159372293 | 9/16/2014 5:27 AM |
| Details | 340B ID | Update | | DSH140155. | DSH140155 | 9/16/2014 5:27 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 9/16/2014 5:26 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 364195126042 | 9/16/2014 5:26 AM |
| Medicaid Billing | Medicaid: State | Insert | | | IL | 9/16/2014 5:26 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 9/16/2014 5:26 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 364195126442 | 9/16/2014 5:26 AM |
| Medicaid Billing | Medicaid: State | Insert | | | IL | 9/16/2014 5:26 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1770678260 | 9/16/2014 5:26 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1336299544 | 9/16/2014 5:26 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1215141627 | 9/16/2014 5:26 AM |
| Details | 340B ID | Update | | DSH140155 | DSH140155. | 9/16/2014 5:26 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | 6/25/2014 12:00:00 AM | | 9/16/2014 5:26 AM |
| Dates | Participating Approval Date | Update | | 5/8/2014 12:00:00 AM | 9/16/2014 12:00:00 AM | 9/16/2014 5:26 AM |
| Details | State | Update | | Terminated | Active | 9/16/2014 5:26 AM |
| Dates | Registration Date | Update | | 4/15/2014 12:00:00 AM | 7/3/2014 12:00:00 AM | 9/16/2014 5:26 AM |
| Dates | Signed By Date | Update | | 4/15/2014 12:00:00 AM | 7/3/2014 12:00:00 AM | 9/16/2014 5:26 AM |
| Dates | Start Date | Update | | 7/1/2014 12:00:00 AM | 10/1/2014 12:00:00 AM | 9/16/2014 5:26 AM |
| Terminations | Termination Comments | Update | | Presence St. Mary's Hospital (PSMH) has never purchsed 340b drugs. This Covered Entity enrolled in the program during the April 2014 window with the goal of 7/1/14 340b eligibility. PSMH is unable to implement a full 340B program and desires to disenroll from the program effective 6/25/14. The chosen "termination reason" is by default in order to process the request. Upon implementation of proper 340b program, this Covered Entity will choose to re-enroll in 340B if it meets all eligibility c | | 9/16/2014 5:26 AM |
| Terminations | Termination Date | Update | | 7/1/2014 12:00:00 AM | | 9/16/2014 5:26 AM |
| Terminations | Termination Effective Date | Update | | 6/25/2014 12:00:00 AM | | 9/16/2014 5:26 AM |
| Terminations | Termination Reason | Update | | Site closure | | 9/16/2014 5:26 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 6/25/2014 12:00:00 AM | 7/2/2014 11:46 PM |
| Details | State | Update | | Active | Terminated | 7/2/2014 11:46 PM |
| Terminations | Termination Comments | Update | | | Presence St. Mary's Hospital (PSMH) has never purchsed 340b drugs. This Covered Entity enrolled in the program during the April 2014 window with the goal of 7/1/14 340b eligibility. PSMH is unable to implement a full 340B program and desires to disenroll from the program effective 6/25/14. The chosen "termination reason" is by default in order to process the request. Upon implementation of proper 340b program, this Covered Entity will choose to re-enroll in 340B if it meets all eligibility c | 7/2/2014 11:46 PM |
| Terminations | Termination Date | Update | | | 7/1/2014 12:00:00 AM | 7/2/2014 11:46 PM |
| Terminations | Termination Effective Date | Update | | | 6/25/2014 12:00:00 AM | 7/2/2014 11:46 PM |
| Terminations | Termination Reason | Update | | | Site closure | 7/2/2014 11:46 PM |
| Dates | Participating Approval Date | Update | | | 5/8/2014 12:00:00 AM | 5/8/2014 7:12 AM |
| Details | State | Update | | Pending | Active | 5/8/2014 7:12 AM |
| Dates | Start Date | Update | | | 7/1/2014 12:00:00 AM | 5/8/2014 7:12 AM |
| Details | 340B ID | Update | | ONLINE_REG | DSH140155 | 4/18/2014 9:36 AM |
| Details | Last Recertification Date | Insert | | | | 4/15/2014 9:49 PM |
| Details | Grant Number | Insert | | | | 4/15/2014 9:49 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 4/15/2014 9:49 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/15/2014 9:49 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/15/2014 9:49 PM |
| Details | Medicare Provider Number | Insert | | | 140155 | 4/15/2014 9:49 PM |
| Details | Entity Name | Insert | | | Presence St. Mary's Hospital | 4/15/2014 9:49 PM |
| Details | Program Code | Insert | | | DSH | 4/15/2014 9:49 PM |
| Details | Entity Subname | Insert | | | | 4/15/2014 9:49 PM |
| Dates | Participating Approval Date | Insert | | | | 4/15/2014 9:49 PM |
| Details | State | Insert | | | Pending | 4/15/2014 9:49 PM |
| Dates | Registration Date | Insert | | | 4/15/2014 12:00:00 AM | 4/15/2014 9:49 PM |
| Dates | Signed By Date | Insert | | | 4/15/2014 12:00:00 AM | 4/15/2014 9:49 PM |
| Dates | Start Date | Insert | | | | 4/15/2014 9:49 PM |
| Terminations | Termination Comments | Insert | | | | 4/15/2014 9:49 PM |
| Terminations | Termination Date | Insert | | | | 4/15/2014 9:49 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/15/2014 9:49 PM |
| Terminations | Termination Reason | Insert | | | | 4/15/2014 9:49 PM |