| Details | Last Recertification Date | Update | Recertification | 8/30/2023 2:56:29 PM | 8/29/2024 3:12:16 PM | 8/29/2024 3:12 PM |
| Details | Last Recertification Date | Update | Recertification | 9/12/2022 2:47:58 PM | 8/30/2023 2:56:29 PM | 8/30/2023 2:56 PM |
| Contacts | Primary Contact | Update | Change Request | Ambord, Hannet T.
Director of Pharmacy
RAMC
6087686295 | McGettigan, Tiaha
Lead Pharmacist
Reedsburg Area Medical Center
6087686223 | 1/10/2023 3:49 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2021 3:53:39 PM | 9/12/2022 2:47:58 PM | 9/12/2022 2:47 PM |
| Details | Entity Subname | Update | Change Request | Reedsburg Area Medical Center Specialty Center | RAMC Specialty Center - Chemotherapy | 1/11/2022 10:28 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 33165100 (WI) | | 10/20/2021 4:17 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1558574830 (WI) | | 10/20/2021 4:17 PM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 100046796 (WI) | | 8/23/2021 3:53 PM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 100075635 (WI) | | 8/23/2021 3:53 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1255832416 (WI) | | 8/23/2021 3:53 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1396857215 (WI) | | 8/23/2021 3:53 PM |
| Details | Last Recertification Date | Update | Recertification | 9/1/2020 12:10:25 PM | 8/23/2021 3:53:39 PM | 8/23/2021 3:53 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 4/8/2021 11:19 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 33165100 | 4/8/2021 11:19 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | WI | 4/8/2021 11:19 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 4/8/2021 11:19 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 100046796 | 4/8/2021 11:19 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | WI | 4/8/2021 11:19 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 4/8/2021 11:19 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 100075635 | 4/8/2021 11:19 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | WI | 4/8/2021 11:19 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1255832416 | 4/8/2021 11:19 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | WI | 4/8/2021 11:19 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1396857215 | 4/8/2021 11:19 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | WI | 4/8/2021 11:19 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1558574830 | 4/8/2021 11:19 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | WI | 4/8/2021 11:19 AM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2019 1:27:07 PM | 9/1/2020 12:10:25 PM | 9/1/2020 12:10 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2018 6:44:27 AM | 8/19/2019 1:27:07 PM | 8/19/2019 1:27 PM |
| Details | Last Recertification Date | Update | Recertification | 11/14/2017 12:13:24 PM | 8/16/2018 6:44:27 AM | 8/16/2018 6:44 AM |
| Addresses | Shipping Address | Insert | Change Request | | Reedsburg Area Medical Center Viking Pharmacy
150 Viking Drive
Reedsburg, WI 53959 | 3/13/2018 3:44 PM |
| Addresses | Shipping Address | Insert | Change Request | | Reedsburg Area Medical Center Community Pharmacy
1900 N. Dewey Avenue
Reedsburg, WI 53959 | 3/13/2018 3:44 PM |
| Details | Last Recertification Date | Update | Recertification | 8/10/2016 12:00:00 AM | 11/14/2017 12:13:24 PM | 11/14/2017 12:13 PM |
| Contacts | Authorizing Official | Update | | VANMEETEREN, ROBERT
CEO/PRESIDENT
6085246487 | VANMEETEREN, ROBERT
CEO/PRESIDENT
Reedsburg Area Medical Center
6085246487 | 11/14/2017 12:07 PM |
| Contacts | Signed By | Update | | VANMEETEREN, ROBERT
CEO/PRESIDENT
6085246487 | VANMEETEREN, ROBERT
CEO/PRESIDENT
Reedsburg Area Medical Center
6085246487 | 11/14/2017 12:07 PM |
| Contacts | Primary Contact | Update | | Ambord, Hannet T.
Director of Pharmacy
6087686295 | Ambord, Hannet T.
Director of Pharmacy
RAMC
6087686295 | 10/24/2017 9:23 AM |
| Addresses | Main Address | Insert | | |
1104 21st Street
Reedsburg, WI 53959 | 6/27/2017 8:00 AM |
| Addresses | Billing Address | Insert | | | Reedsburg Area Medical Center
2000 N Dewey Avenue
Reedsburg, WI 53959 | 6/27/2017 8:00 AM |
| Addresses | Shipping Address | Insert | | | Reedsburg Area Medical Center
2000 N Dewey Avenue
Reedsburg, WI 53959 | 6/27/2017 8:00 AM |
| Contacts | Primary Contact | Update | | Steiner, Matt
Director of Pharmacy
6087686295 | Ambord, Hannet T.
Director of Pharmacy
6087686295 | 6/27/2017 8:00 AM |
| Contacts | Authorizing Official | Insert | | | VANMEETEREN, ROBERT
CEO/PRESIDENT
6085246487 | 6/27/2017 8:00 AM |
| Contacts | Signed By | Insert | | | VANMEETEREN, ROBERT
CEO/PRESIDENT
6085246487 | 6/27/2017 8:00 AM |
| Details | Last Recertification Date | Update | | | 8/10/2016 12:00:00 AM | 8/10/2016 11:33 AM |
| Contacts | Primary Contact | Insert | | | Steiner, Matt
Director of Pharmacy
6087686295 | 10/22/2015 4:21 PM |
| Dates | Participating Approval Date | Update | | | 10/22/2015 12:00:00 AM | 10/22/2015 4:21 PM |
| Details | State | Update | | Pending | Active | 10/22/2015 4:21 PM |
| Dates | Start Date | Update | | | 1/1/2016 12:00:00 AM | 10/22/2015 4:21 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_54874 | CAH521351-02 | 10/14/2015 10:05 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_54874 | 10/9/2015 11:33 AM |
| Details | Last Recertification Date | Insert | | | | 10/9/2015 11:33 AM |
| Details | Grant Number | Insert | | | | 10/9/2015 11:33 AM |
| Details | 340B ID | Insert | | | | 10/9/2015 11:33 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/9/2015 11:33 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/9/2015 11:33 AM |
| Details | Medicare Provider Number | Insert | | | 521351 | 10/9/2015 11:33 AM |
| Details | Entity Name | Insert | | | REEDSBURG AREA MEDICAL CENTER | 10/9/2015 11:33 AM |
| Details | Program Code | Insert | | | CAH | 10/9/2015 11:33 AM |
| Details | Entity Subname | Insert | | | Reedsburg Area Medical Center Specialty Center | 10/9/2015 11:33 AM |
| Dates | Participating Approval Date | Insert | | | | 10/9/2015 11:33 AM |
| Details | State | Insert | | | Pending | 10/9/2015 11:33 AM |
| Dates | Registration Date | Insert | | | 10/9/2015 12:00:00 AM | 10/9/2015 11:33 AM |
| Dates | Signed By Date | Insert | | | 10/9/2015 12:00:00 AM | 10/9/2015 11:33 AM |
| Dates | Start Date | Insert | | | | 10/9/2015 11:33 AM |
| Terminations | Termination Comments | Insert | | | | 10/9/2015 11:33 AM |
| Terminations | Termination Date | Insert | | | | 10/9/2015 11:33 AM |
| Terminations | Termination Effective Date | Insert | | | | 10/9/2015 11:33 AM |
| Terminations | Termination Reason | Insert | | | | 10/9/2015 11:33 AM |