| Contacts | Authorizing Official | Update | Profile Change Request | Dalal, Hardik
SVP, Finance CHW
Corewell Health
3127710810 | Dalal, Hardik
SVP, Finance & System-wide Pharmacy Finance
Corewell Health
3127710810 | 2/24/2025 6:26 AM |
| Details | Entity Name | Update | Recertification | Botsford General Hospital d/b/a Beaumont Hospital - Farmington Hills | Botsford General Hospital d/b/a Corewell Health Farmington Hills Hospital | 9/5/2024 8:25 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2023 2:44:13 PM | 9/3/2024 2:10:44 PM | 9/3/2024 2:10 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Schaible, Thomas
340B Pharmacy Manager
Corewell Health
9475221169 | Schaible, Thomas
Mgr, Pharmacy CHE
Corewell Health
9475221169 | 1/30/2024 8:36 AM |
| Contacts | Primary Contact | Update | PC Change Request | Schaible, Thomas
Manager 340B Pharmacy
Beaumont Hospital, Grosse Pointe
9475221169 | Schaible, Thomas
340B Pharmacy Manager
Corewell Health
9475221169 | 1/10/2024 12:26 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Susick, Nancy Ann
COO
Beaumont Health
9475223349 | Dalal, Hardik
SVP, Finance CHW
Corewell Health
3127710810 | 12/13/2023 8:06 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2022 2:46:35 PM | 8/21/2023 2:44:13 PM | 8/21/2023 2:44 PM |
| Contacts | Primary Contact | Update | PC Change Request | Nastwold, Scott
Director, Pharmacy Services
Beaumont Health
2484718356 | Schaible, Thomas
Manager 340B Pharmacy
Beaumont Hospital, Grosse Pointe
9475221169 | 10/13/2022 11:25 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Odom, Lee Ann
President, Shared Services
Beaumont Health
9475222653 | Susick, Nancy Ann
COO
Beaumont Health
9475223349 | 10/11/2022 10:05 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2021 9:42:29 AM | 8/29/2022 2:46:35 PM | 8/29/2022 2:46 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2020 4:13:08 PM | 8/30/2021 9:42:29 AM | 8/30/2021 9:42 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
9475223338 | Odom, Lee Ann
President, Shared Services
Beaumont Health
9475222653 | 8/16/2021 8:47 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | MI | 8/31/2020 4:13 PM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2019 11:23:18 AM | 8/31/2020 4:13:08 PM | 8/31/2020 4:13 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
2482133338 | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
9475223338 | 6/2/2020 8:31 AM |
| Details | Entity Subname | Update | Change Request | BOTSFORD RHEUMATOLOGY ASSOCIATES | BEAUMONT RHEUMATOLOGY ASSOCIATES (Dept# 730170) -Rheumatology Bone Densometer | 3/11/2020 9:14 AM |
| Details | Entity Name | Update | Change Request | BOTSFORD HOSPITAL | Botsford General Hospital d/b/a Beaumont Hospital - Farmington Hills | 3/11/2020 9:05 AM |
| Contacts | Primary Contact | Update | Recertification | Nostwold, Scott
Director of Pharmacy
Bostford
2484718356 | Nastwold, Scott
Director, Pharmacy Services
Beaumont Health
2484718356 | 9/10/2019 11:23 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2018 10:31:00 AM | 9/10/2019 11:23:18 AM | 9/10/2019 11:23 AM |
| Details | Last Recertification Date | Update | Recertification | 11/15/2017 12:40:47 PM | 8/16/2018 10:31:00 AM | 8/16/2018 10:31 AM |
| Contacts | Primary Contact | Update | Recertification | Nastwold, Scott
Director of Pharmacy
2484718356 | Nostwold, Scott
Director of Pharmacy
Bostford
2484718356 | 11/15/2017 12:40 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2016 12:00:00 AM | 11/15/2017 12:40:47 PM | 11/15/2017 12:40 PM |
| Contacts | Authorizing Official | Update | | Wilson, Carolyn
Chief Operating Officer
2482133338 | Wilson, Carolyn
Chief Operating Officer
Beaumont Health
2482133338 | 10/12/2017 10:32 AM |
| Contacts | Authorizing Official | Insert | | | Wilson, Carolyn
Chief Operating Officer
2482133338 | 7/3/2017 1:01 PM |
| Addresses | Main Address | Insert | | |
28100 GRAND RIVER AVE
SUITE 314
FARMINGTON HILLS, MI 48336-5970 | 5/10/2017 5:54 PM |
| Contacts | Signed By | Insert | | | LaCasse, Paul
President & Chief Executive Officer
2484718949 | 5/10/2017 5:54 PM |
| Contacts | Primary Contact | Insert | | | Nastwold, Scott
Director of Pharmacy
2484718356 | 5/10/2017 5:54 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1336183367 | 3/14/2017 11:16 AM |
| Details | Last Recertification Date | Update | | 8/25/2015 12:00:00 AM | 8/31/2016 12:00:00 AM | 8/31/2016 3:46 PM |
| Details | Last Recertification Date | Update | | | 8/25/2015 12:00:00 AM | 8/25/2015 1:12 PM |
| Details | Entity Name | Update | | BOTSFORD HOSPTIAL | BOTSFORD HOSPITAL | 3/11/2015 5:42 PM |
| Dates | Participating Approval Date | Update | | | 3/11/2015 12:00:00 AM | 3/11/2015 5:42 PM |
| Details | State | Update | | Pending | Active | 3/11/2015 5:42 PM |
| Dates | Start Date | Update | | | 4/1/2015 12:00:00 AM | 3/11/2015 5:42 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_49425 | DSH230151A | 1/27/2015 10:20 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_49425 | 1/14/2015 5:38 PM |
| Details | Last Recertification Date | Insert | | | | 1/14/2015 5:38 PM |
| Details | Grant Number | Insert | | | | 1/14/2015 5:38 PM |
| Details | 340B ID | Insert | | | | 1/14/2015 5:38 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/14/2015 5:38 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/14/2015 5:38 PM |
| Details | Medicare Provider Number | Insert | | | 230151 | 1/14/2015 5:38 PM |
| Details | Entity Name | Insert | | | BOTSFORD HOSPTIAL | 1/14/2015 5:38 PM |
| Details | Program Code | Insert | | | DSH | 1/14/2015 5:38 PM |
| Details | Entity Subname | Insert | | | BOTSFORD RHEUMATOLOGY ASSOCIATES | 1/14/2015 5:38 PM |
| Dates | Participating Approval Date | Insert | | | | 1/14/2015 5:38 PM |
| Details | State | Insert | | | Pending | 1/14/2015 5:38 PM |
| Dates | Registration Date | Insert | | | 1/14/2015 12:00:00 AM | 1/14/2015 5:38 PM |
| Dates | Signed By Date | Insert | | | 1/14/2015 12:00:00 AM | 1/14/2015 5:38 PM |
| Dates | Start Date | Insert | | | | 1/14/2015 5:38 PM |
| Terminations | Termination Comments | Insert | | | | 1/14/2015 5:38 PM |
| Terminations | Termination Date | Insert | | | | 1/14/2015 5:38 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/14/2015 5:38 PM |
| Terminations | Termination Reason | Insert | | | | 1/14/2015 5:38 PM |