Covered Entity Details

CAH231322-02 MUNSON HEALTHCARE CHARLEVOIX HOSPITAL (Terminated) - information as of 4/24/2025 11:10:37 PM

Main Details

Name

MUNSON HEALTHCARE CHARLEVOIX HOSPITAL

Subdivision Name

MUNSON HEALTHCARE / Jordan Valley Rehab Center

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH231322-02

Medicare Provider Number

231322

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/8/2014

Participating Start Date

1/1/2015

Participating Approval Date

12/5/2014

Last Recertification Date

8/20/2019

Termination Date
Termination Reason

10/1/2020
Business decision by the Covered Entity

Contacts

Authorizing Official

Munson Healthcare
Mark Hepler, CFO
(231) 935-6702

Primary Contact

Munson Healthcare
Steve Leach, Regional Director, Reimbursement
(231) 935-7797

Addresses

Street Address

100 MAIN STREET
EAST JORDAN, MI 49727-0455

Billing Address

Munson Healthcare Charlevoix Hospital
14700 Lake Shore Dr
Charlevoix, MI 49720

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?
No

Shipping Addresses

Shipping Address 1

Munson Healthcare Charlevoix Hospital
14700 Lake Shore Dr
Charlevoix, MI 49720

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH231322-01	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	MUNSON HEALTHCARE / Boyne Rehab Center	197 STATE STREET	BOYNE CITY	MI	Terminated
CAH231322-02	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	MUNSON HEALTHCARE / Jordan Valley Rehab Center	100 MAIN STREET	EAST JORDAN	MI	Terminated
CAH231322-03	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	MUNSON HEALTHCARE / Charlevoix Primary Care	14734 PARK AVENUE	CHARLEVOIX	MI	Active
CAH231322-04	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	MUNSON HEALTHCARE / Charlevoix Family Medicine	14705 W. Upright St.	Charlevoix	MI	Terminated
CAH231322-05	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	MUNSON HEALTHCARE / Charlevoix Physician's Clinic	14709 W UPRIGHT STREET	CHARLEVOIX	MI	Active
CAH231322-06	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	MUNSON HEALTHCARE / Charlevoix Women's Health	14651 W UPRIGHT ST	CHARLEVOIX	MI	Active
CAH231322-07	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	Munson Healthcare Boyne Area Health Center	223 N Park St.	Boyne City	MI	Active
CAH231322-08	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	MUNSON HEALTHCARE / Charlevoix Physician's Clinic - Pediatrics	14719 W Upright St	Charlevoix	MI	Active
CAH231322-09	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	Munson Healthcare Charlevoix Behavioral Health - Behavioral Health Services	14695 Park Ave	Charlevoix	MI	Active
CAH231322-10	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	Charlevoix Physician's Clinic - Sleep Disorders Medicine	14695 Park Ave.	Charlevoix	MI	Active
CAH231322-11	Child	CAH	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	Charlevoix Surgeons - General Surgery	14695 Park Avenue	Charlevoix	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		8/13/2020 12:00:00 AM	8/20/2020 7:16 AM
Details	State	Update	Termination Request	Active	To Be Terminated	8/20/2020 7:16 AM
Terminations	Termination Comments	Update	Termination Request		There isn't any 340b drugs happening at this location and there are no physicians. It is still an eligible site, we just aren't going to operate 340b there.	8/20/2020 7:16 AM
Terminations	Termination Date	Update	Termination Request		10/1/2020 12:00:00 AM	8/20/2020 7:16 AM
Terminations	Termination Effective Date	Update	Termination Request		10/1/2020 12:00:00 AM	8/20/2020 7:16 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	8/20/2020 7:16 AM
Details	Last Recertification Date	Update	Recertification	8/28/2018 1:34:25 PM	8/20/2019 12:56:30 PM	8/20/2019 12:56 PM
Contacts	Primary Contact	Update	Change Request	HAWKINS, JOSEPH Pharmacy Manager Munson Healthcare Charlevoix Hospital 2315478590	Leach, Steve Regional Director, Reimbursement Munson Healthcare 2319357797	6/3/2019 9:32 AM
Details	Last Recertification Date	Update	Recertification	12/4/2017 10:56:45 AM	8/28/2018 1:34:25 PM	8/28/2018 1:34 PM
Contacts	Authorizing Official	Update	AO Change Request	Schroeder, Joanne CEO Munson Healthcare Charlevoix Hospital 2315478500	Hepler, Mark CFO Munson Healthcare 2319356702	4/10/2018 7:10 AM
Contacts	Primary Contact	Update	Recertification	Jenks, Lyn A. CEO 2315478500	HAWKINS, JOSEPH Pharmacy Manager Munson Healthcare Charlevoix Hospital 2315478590	12/4/2017 10:56 AM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	12/4/2017 10:56:45 AM	12/4/2017 10:56 AM
Contacts	Authorizing Official	Update		Schroeder, Joanne CEO 2315478500	Schroeder, Joanne CEO Munson Healthcare Charlevoix Hospital 2315478500	10/17/2017 9:45 AM
Contacts	Authorizing Official	Update		Jenks, Lyn A. CEO 2315478500	Schroeder, Joanne CEO 2315478500	9/11/2017 3:29 PM
Contacts	Signed By	Insert			Jenks, Lyn A. Chief Executive Officer 2315478500	8/11/2017 8:36 AM
Contacts	Authorizing Official	Insert			Jenks, Lyn A. CEO 2315478500	4/19/2017 10:56 AM
Contacts	Primary Contact	Insert			Jenks, Lyn A. CEO 2315478500	4/19/2017 10:56 AM
Addresses	Main Address	Insert			100 MAIN STREET EAST JORDAN, MI 49727-0455	4/19/2017 10:56 AM
Addresses	Billing Address	Insert			Munson Healthcare Charlevoix Hospital 14700 Lake Shore Dr Charlevoix, MI 49720	4/19/2017 10:56 AM
Addresses	Shipping Address	Insert			Munson Healthcare Charlevoix Hospital 14700 Lake Shore Dr Charlevoix, MI 49720	4/19/2017 10:56 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 11:07 AM
Details	Entity Name	Update		CHARLEVOIX AREA HOSPITAL	MUNSON HEALTHCARE CHARLEVOIX HOSPITAL	12/3/2015 10:51 AM
Details	Entity Subname	Update		JORDAN VALLEY REHABILITATION CENTER	MUNSON HEALTHCARE / Jordan Valley Rehab Center	12/3/2015 10:51 AM
Details	Last Recertification Date	Update			8/5/2015 12:00:00 AM	8/5/2015 10:28 AM
Dates	Participating Approval Date	Update			12/5/2014 12:00:00 AM	12/5/2014 1:10 PM
Details	State	Update		Pending	Active	12/5/2014 1:10 PM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	12/5/2014 1:10 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_46697	CAH231322-02	11/26/2014 1:33 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_46697	10/8/2014 11:12 AM
Details	Last Recertification Date	Insert				10/8/2014 11:12 AM
Details	Grant Number	Insert				10/8/2014 11:12 AM
Details	340B ID	Insert				10/8/2014 11:12 AM
Details	Is Authorizing Official EHB Data	Insert				10/8/2014 11:12 AM
Dates	Last Date That 340B Drugs Purchased	Insert				10/8/2014 11:12 AM
Details	Medicare Provider Number	Insert			231322	10/8/2014 11:12 AM
Details	Entity Name	Insert			CHARLEVOIX AREA HOSPITAL	10/8/2014 11:12 AM
Details	Program Code	Insert			CAH	10/8/2014 11:12 AM
Details	Entity Subname	Insert			JORDAN VALLEY REHABILITATION CENTER	10/8/2014 11:12 AM
Dates	Participating Approval Date	Insert				10/8/2014 11:12 AM
Details	State	Insert			Pending	10/8/2014 11:12 AM
Dates	Registration Date	Insert			10/8/2014 12:00:00 AM	10/8/2014 11:12 AM
Dates	Signed By Date	Insert			10/8/2014 12:00:00 AM	10/8/2014 11:12 AM
Dates	Start Date	Insert				10/8/2014 11:12 AM
Terminations	Termination Comments	Insert				10/8/2014 11:12 AM
Terminations	Termination Date	Insert				10/8/2014 11:12 AM
Terminations	Termination Effective Date	Insert				10/8/2014 11:12 AM
Terminations	Termination Reason	Insert				10/8/2014 11:12 AM