| 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 | 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 |
| 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 | | Janicek, Kimberly
Regional Directir of Pharmacy
8157417142 | Janicek, Kimberly
Regional Directir of Pharmacy
Presence Health
8157417142 | 10/12/2017 12:39 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 |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 10/1/2014 12:00:00 AM | 10/6/2015 8:30 AM |
| Details | State | Update | | Active | Terminated | 10/6/2015 8:30 AM |
| Terminations | Termination Comments | Update | | | We have never made any 340B drug purchases for this child site location and would like to disenroll from the program. | 10/6/2015 8:30 AM |
| Terminations | Termination Date | Update | | | 1/1/2016 12:00:00 AM | 10/6/2015 8:30 AM |
| Terminations | Termination Effective Date | Update | | | 10/1/2015 12:00:00 AM | 10/6/2015 8:30 AM |
| Terminations | Termination Reason | Update | | | Site closure | 10/6/2015 8:30 AM |
| Addresses | Main Address | Insert | | |
100 Provena Way
Bourbonnais, IL 60914 | 10/6/2015 8:29 AM |
| Addresses | Billing Address | Insert | | | Presence St. Mary's Hospital
500 West Court Street
Kankakee, IL 60901 | 10/6/2015 8:29 AM |
| 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 |
| Dates | Last Date That 340B Drugs Purchased | Update | | 6/25/2014 12:00:00 AM | | 9/16/2014 11:38 AM |
| Details | Entity Subname | Update | | Bourbonnais Imaging | Bourbonnais Campus - OP Imaging | 9/16/2014 11:38 AM |
| Details | State | Update | | Terminated | Active | 9/16/2014 11:38 AM |
| Dates | Start Date | Update | | 7/1/2014 12:00:00 AM | 10/1/2014 12:00:00 AM | 9/16/2014 11:38 AM |
| Terminations | Termination Comments | Update | | Presence St. Mary's Hospital has never purchased 340b drugs. This Covered Entity 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 criteria. This Covered Entity understands and appreciates the importance of the 340B program and desires to | | 9/16/2014 11:38 AM |
| Terminations | Termination Date | Update | | 7/1/2014 12:00:00 AM | | 9/16/2014 11:38 AM |
| Terminations | Termination Effective Date | Update | | 6/25/2014 12:00:00 AM | | 9/16/2014 11:38 AM |
| Terminations | Termination Reason | Update | | Site closure | | 9/16/2014 11:38 AM |
| Details | Comments Public | Insert | | | 9/16/14 originally registered for a 7/1/14 start date then, prior to start date, terminated because hospital was not ready to implement 340B. Subsequently re-registered during July registration period and so the old record was re-instated effective 10/1/14 | 9/16/2014 11:38 AM |
| Contacts | Primary Contact | Insert | | | Meyer, Emily
Regional Director of Pharmacy
8159372293 | 9/16/2014 5:27 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 6/25/2014 12:00:00 AM | 7/2/2014 11:48 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 | Presence St. Mary's Hospital has never purchased 340b drugs. This Covered Entity 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 criteria. This Covered Entity understands and appreciates the importance of the 340B program and desires to | 7/2/2014 11:48 PM |
| Terminations | Termination Effective Date | Update | | | 6/25/2014 12:00:00 AM | 7/2/2014 11:48 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 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 7:14 AM |
| Details | State | Update | | Pending | Active | 5/8/2014 7:14 AM |
| Dates | Start Date | Update | | | 7/1/2014 12:00:00 AM | 5/8/2014 7:14 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | DSH140155F | 4/18/2014 11:29 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/15/2014 9:57 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 364195126042 | 4/15/2014 9:57 PM |
| Medicaid Billing | Medicaid: State | Insert | | | IL | 4/15/2014 9:57 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/15/2014 9:57 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 364195126442 | 4/15/2014 9:57 PM |
| Medicaid Billing | Medicaid: State | Insert | | | IL | 4/15/2014 9:57 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1770678260 | 4/15/2014 9:57 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1215141627 | 4/15/2014 9:57 PM |
| Details | Last Recertification Date | Insert | | | | 4/15/2014 9:57 PM |
| Details | Grant Number | Insert | | | | 4/15/2014 9:57 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 4/15/2014 9:57 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/15/2014 9:57 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/15/2014 9:57 PM |
| Details | Medicare Provider Number | Insert | | | 140155 | 4/15/2014 9:57 PM |
| Details | Entity Name | Insert | | | Presence St. Mary's Hospital | 4/15/2014 9:57 PM |
| Details | Program Code | Insert | | | DSH | 4/15/2014 9:57 PM |
| Details | Entity Subname | Insert | | | Bourbonnais Imaging | 4/15/2014 9:57 PM |
| Dates | Participating Approval Date | Insert | | | | 4/15/2014 9:57 PM |
| Details | State | Insert | | | Pending | 4/15/2014 9:57 PM |
| Dates | Registration Date | Insert | | | 4/15/2014 12:00:00 AM | 4/15/2014 9:57 PM |
| Dates | Signed By Date | Insert | | | 4/15/2014 12:00:00 AM | 4/15/2014 9:57 PM |
| Dates | Start Date | Insert | | | | 4/15/2014 9:57 PM |
| Terminations | Termination Comments | Insert | | | | 4/15/2014 9:57 PM |
| Terminations | Termination Date | Insert | | | | 4/15/2014 9:57 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/15/2014 9:57 PM |
| Terminations | Termination Reason | Insert | | | | 4/15/2014 9:57 PM |