| Contacts | Authorizing Official | Update | AO Change Request | Lyren, Joseph S
VP Finance
OhioHealth
4195268417 | Gingrich, Curtis L
President
OhioHealth
4195268403 | 12/17/2024 8:00 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2023 2:38:56 PM | 8/30/2024 10:01:17 AM | 8/30/2024 10:01 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2022 2:20:06 PM | 9/8/2023 2:38:56 PM | 9/8/2023 2:38 PM |
| Addresses | Shipping Address | Update | Change Request | MEDCENTRAL HEALTH SYSTEM
335 Glessner Ave
Mansfield, OH 44903-2265 | MEDCENTRAL HEALTH SYSTEM
335 Glessner Ave
Mansfield, OH 44903-2269 | 7/10/2023 7:21 AM |
| Addresses | Main Address | Update | Change Request |
335 GLESSNER AVE
MANSFIELD, OH 44903-2265 |
335 GLESSNER AVE
MANSFIELD, OH 44903-2269 | 7/10/2023 7:21 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Lyren, Joseph S
VP Finance North Market
OhioHealth
4195268417 | Lyren, Joseph S
VP Finance
OhioHealth
4195268417 | 8/30/2022 6:06 AM |
| Addresses | Billing Address | Insert | Recertification | | OhioHealth
PO Box 9
Columbus, OH 43216 | 8/29/2022 2:20 PM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2021 10:38:01 AM | 8/29/2022 2:20:06 PM | 8/29/2022 2:20 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 8/19/2021 10:38 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 0418885 | 8/19/2021 10:38 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | OH | 8/19/2021 10:38 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1629696802 | 8/19/2021 10:38 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | OH | 8/19/2021 10:38 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2020 7:44:52 AM | 8/19/2021 10:38:01 AM | 8/19/2021 10:38 AM |
| Addresses | Shipping Address | Insert | Change Request | | OhioHealth Mansfield Hospital DBA Mansfield Retail Pharmacy
335 Glessner Ave
Mansfield, OH 44903-2269 | 9/29/2020 1:20 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | OH | 9/9/2020 7:44 AM |
| Contacts | Primary Contact | Update | Recertification | George, Brian
Pharmacy Site Manager
OhioHealth
4195268843 | Brahimaj, Eva
Site Manager
OhioHealh
4195268084 | 9/9/2020 7:44 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2019 12:00:28 PM | 9/9/2020 7:44:52 AM | 9/9/2020 7:44 AM |
| Details | Entity Name | Update | Recertification | MEDCENTRAL HEALTH SYSTEM | MEDCENTRAL HEALTH SYSTEM DBA OHIOHEALTH MANSFIELD HOSPITAL | 9/9/2020 7:44 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Lyren, Joseph S
VP Finance
OhioHealth Mansfield and Shelby Hospitals
4195268417 | Lyren, Joseph S
VP Finance North Market
OhioHealth
4195268417 | 8/24/2020 11:12 AM |
| Addresses | Shipping Address | Insert | Change Request | | MEDCENTRAL HEALTH SYSTEM
335 Glessner Ave
Mansfield, OH 44903-2265 | 8/27/2019 7:08 AM |
| Addresses | Shipping Address | Insert | Change Request | | Safecor Health, LLC
4060 Business Park Drive
Suite B
Columbus, OH 43204 | 8/27/2019 7:08 AM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2018 4:15:38 PM | 8/26/2019 12:00:28 PM | 8/26/2019 12:00 PM |
| Details | Last Recertification Date | Update | Recertification | 11/15/2017 10:55:26 AM | 9/11/2018 4:15:38 PM | 9/11/2018 4:15 PM |
| Contacts | Authorizing Official | Update | Change Request | Halpin, Jean
President
OhioHealth
4195268400 | Lyren, Joseph S
VP Finance
OhioHealth Mansfield and Shelby Hospitals
4195268417 | 8/27/2018 1:36 PM |
| Details | Last Recertification Date | Update | Recertification | 8/15/2016 12:00:00 AM | 11/15/2017 10:55:26 AM | 11/15/2017 10:55 AM |
| Contacts | Primary Contact | Update | Recertification | George, Brian
Pharmacy Site Manager
4195268843 | George, Brian
Pharmacy Site Manager
OhioHealth
4195268843 | 11/14/2017 5:27 PM |
| Contacts | Authorizing Official | Update | | Halpin, Jean
President
4195268400 | Halpin, Jean
President
OhioHealth
4195268400 | 11/14/2017 5:20 PM |
| Contacts | Authorizing Official | Insert | | | Halpin, Jean
President
4195268400 | 8/2/2017 2:14 PM |
| Addresses | Main Address | Insert | | |
335 GLESSNER AVE
MANSFIELD, OH 44903-2265 | 11/15/2016 12:23 PM |
| Contacts | Signed By | Insert | | | Bichimer, Michael
Vice President, Finance
4195268417 | 11/15/2016 12:23 PM |
| Contacts | Primary Contact | Insert | | | George, Brian
Pharmacy Site Manager
4195268843 | 11/15/2016 12:23 PM |
| Details | Last Recertification Date | Update | | | 8/15/2016 12:00:00 AM | 8/15/2016 10:11 AM |
| Dates | Participating Approval Date | Update | | | 4/28/2016 12:00:00 AM | 4/28/2016 3:41 PM |
| Details | State | Update | | Pending | Active | 4/28/2016 3:41 PM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 4/28/2016 3:41 PM |
| Details | 340B ID | Update | | ONLINE_REG_59565 | DSH360118 | 4/28/2016 10:29 AM |
| Details | 340B ID | Update | | | ONLINE_REG_59565 | 4/11/2016 2:11 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/11/2016 2:11 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 5489663 | 4/11/2016 2:11 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 4/11/2016 2:11 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1790837235 | 4/11/2016 2:11 PM |
| Details | Last Recertification Date | Insert | | | | 4/11/2016 2:11 PM |
| Details | Grant Number | Insert | | | | 4/11/2016 2:11 PM |
| Details | 340B ID | Insert | | | | 4/11/2016 2:11 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/11/2016 2:11 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/11/2016 2:11 PM |
| Details | Medicare Provider Number | Insert | | | 360118 | 4/11/2016 2:11 PM |
| Details | Entity Name | Insert | | | MEDCENTRAL HEALTH SYSTEM | 4/11/2016 2:11 PM |
| Details | Program Code | Insert | | | DSH | 4/11/2016 2:11 PM |
| Details | Entity Subname | Insert | | | | 4/11/2016 2:11 PM |
| Dates | Participating Approval Date | Insert | | | | 4/11/2016 2:11 PM |
| Details | State | Insert | | | Pending | 4/11/2016 2:11 PM |
| Dates | Registration Date | Insert | | | 4/11/2016 12:00:00 AM | 4/11/2016 2:11 PM |
| Dates | Signed By Date | Insert | | | 4/11/2016 12:00:00 AM | 4/11/2016 2:11 PM |
| Dates | Start Date | Insert | | | | 4/11/2016 2:11 PM |
| Terminations | Termination Comments | Insert | | | | 4/11/2016 2:11 PM |
| Terminations | Termination Date | Insert | | | | 4/11/2016 2:11 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/11/2016 2:11 PM |
| Terminations | Termination Reason | Insert | | | | 4/11/2016 2:11 PM |