| Details | Last Recertification Date | Update | Recertification | 2/2/2024 11:44:12 AM | 2/10/2025 3:18:01 PM | 2/10/2025 3:18 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2023 1:17:21 PM | 2/2/2024 11:44:12 AM | 2/2/2024 11:44 AM |
| Details | Last Recertification Date | Update | Recertification | 2/2/2022 8:39:21 AM | 1/31/2023 1:17:21 PM | 1/31/2023 1:17 PM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2021 12:05:48 PM | 2/2/2022 8:39:21 AM | 2/2/2022 8:39 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1295258200 | 2/3/2021 12:05 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | WI | 2/3/2021 12:05 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1295258200 ( ) | | 2/3/2021 12:05 PM |
| Details | Last Recertification Date | Update | Recertification | 1/28/2020 5:17:28 PM | 2/3/2021 12:05:48 PM | 2/3/2021 12:05 PM |
| Addresses | Billing Address | Update | Change Request | Lakeshore Community Health Care, Inc.
1721 Saemann Ave.
Sheboygan, WI 53081-0959 | Lakeshore Community Health Care, Inc.
PO Box 959
Sheboygan, WI 53082-0959 | 1/4/2021 4:41 PM |
| Addresses | Shipping Address | Insert | Change Request | | Lakeshore Community Health Care, Inc. DBA Lakeshore Pharmacy
1721 Saemann Ave.
Sheboygan, WI 53081-2342 | 10/23/2020 9:05 AM |
| Addresses | Shipping Address | Insert | Change Request | | Lakeshore Community Health Care, Inc. DBA Lakeshore Pharmacy
Lakeshore Prescription Services
2719 Calumet Ave.
A
Manitowoc, WI 54220-5546 | 10/23/2020 9:05 AM |
| Addresses | Main Address | Update | Change Request |
Lakeshore Pharmacy
1721 Saemann Ave.
Sheboygan, WI 53081-2342 |
1721 Saemann Ave.
Sheboygan, WI 53081-2342 | 10/23/2020 9:05 AM |
| Addresses | Billing Address | Update | Change Request | Lakeshore Community Health Care, Inc.
PO Box 959
Sheboygan, WI 53082-0959 | Lakeshore Community Health Care, Inc.
1721 Saemann Ave.
Sheboygan, WI 53081-0959 | 10/23/2020 9:05 AM |
| Details | Last Recertification Date | Update | Recertification | 2/1/2019 9:54:10 AM | 1/28/2020 5:17:28 PM | 1/28/2020 5:17 PM |
| Details | Last Recertification Date | Update | Recertification | 2/8/2018 12:35:41 PM | 2/1/2019 9:54:10 AM | 2/1/2019 9:54 AM |
| Details | Last Recertification Date | Update | Recertification | 2/14/2017 12:00:00 AM | 2/8/2018 12:35:41 PM | 2/8/2018 12:35 PM |
| Medicaid Billing | Medicaid: Number | Update | Change Request | 1043733447 | 1295258200 | 9/20/2017 3:43 PM |
| Details | Is Authorizing Official EHB Data | Update | Change Request | False | | 9/20/2017 3:43 PM |
| Contacts | Authorizing Official | Update | | Stearns, Kristin
CEO
9207836633-204 | Stearns, Kristin Blanchard
CEO
Lakeshore Community Health Care
9207836633-204 | 9/20/2017 3:41 PM |
| Contacts | Primary Contact | Update | | Wilson, Christa
Director of Pharmacy
9207836633-255 | Wilson, Christa
Director of Pharmacy
Lakeshore Community Health Care
9207836633-255 | 9/19/2017 11:54 AM |
| Addresses | Main Address | Insert | | |
Lakeshore Pharmacy
1721 Saemann Ave.
Sheboygan, WI 53081-2342 | 8/4/2017 8:04 AM |
| Addresses | Billing Address | Insert | | | Lakeshore Community Health Care, Inc.
PO Box 959
Sheboygan, WI 53082-0959 | 8/4/2017 8:04 AM |
| Contacts | Authorizing Official | Insert | | | Stearns, Kristin
CEO
9207836633-204 | 8/4/2017 8:04 AM |
| Contacts | Primary Contact | Insert | | | Wilson, Christa
Director of Pharmacy
9207836633-255 | 8/4/2017 8:04 AM |
| Contacts | Signed By | Insert | | | Hughes, David E.
CFO/COO
9207836633-201 | 8/4/2017 8:04 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 8/4/2017 8:03 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 1043733447 | 8/4/2017 8:03 AM |
| Medicaid Billing | Medicaid: State | Insert | | | WI | 8/4/2017 8:03 AM |
| Medicaid Billing | NPI: Number | Insert | | | 1295258200 | 8/4/2017 8:03 AM |
| Details | Last Recertification Date | Update | | 3/2/2016 12:00:00 AM | 2/14/2017 12:00:00 AM | 2/14/2017 10:12 AM |
| Details | Last Recertification Date | Update | | | 3/2/2016 12:00:00 AM | 3/2/2016 11:43 AM |
| Dates | Participating Approval Date | Update | | | 7/10/2015 12:00:00 AM | 7/10/2015 10:53 AM |
| Details | State | Update | | Pending | Active | 7/10/2015 10:53 AM |
| Dates | Start Date | Update | | | 10/1/2015 12:00:00 AM | 7/10/2015 10:53 AM |
| Details | 340B ID | Update | | ONLINE_REG_52817 | CHC24152-02 | 7/9/2015 12:52 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_52817 | 7/9/2015 12:49 PM |
| Details | Last Recertification Date | Insert | | | | 7/9/2015 12:49 PM |
| Details | Grant Number | Insert | | | H80CS24152 | 7/9/2015 12:49 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 7/9/2015 12:49 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 7/9/2015 12:49 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/9/2015 12:49 PM |
| Details | Medicare Provider Number | Insert | | | | 7/9/2015 12:49 PM |
| Details | Entity Name | Insert | | | LAKESHORE COMMUNITY HEALTH CARE, INC | 7/9/2015 12:49 PM |
| Details | Program Code | Insert | | | CH | 7/9/2015 12:49 PM |
| Details | Entity Subname | Insert | | | Lakeshore Community Health Care Medical/BH | 7/9/2015 12:49 PM |
| Dates | Participating Approval Date | Insert | | | | 7/9/2015 12:49 PM |
| Details | State | Insert | | | Pending | 7/9/2015 12:49 PM |
| Dates | Registration Date | Insert | | | 7/9/2015 12:00:00 AM | 7/9/2015 12:49 PM |
| Dates | Signed By Date | Insert | | | 7/9/2015 12:00:00 AM | 7/9/2015 12:49 PM |
| Dates | Start Date | Insert | | | | 7/9/2015 12:49 PM |
| Terminations | Termination Comments | Insert | | | | 7/9/2015 12:49 PM |
| Terminations | Termination Date | Insert | | | | 7/9/2015 12:49 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/9/2015 12:49 PM |
| Terminations | Termination Reason | Insert | | | | 7/9/2015 12:49 PM |