Covered Entity Details

CHC29834-00 PROMISE HEALTHCARE NFP (Active) - information as of 5/23/2025 12:17:28 AM

Main Details

Name

PROMISE HEALTHCARE NFP

Subdivision Name

Frances Nelson

Type

HRSA-Funded Health Center

Site ID

BPS-H80-017987

340B ID

CHC29834-00

Grant Number

H80CS29834

Additional Details

Current Program Status

Active

Registration Date

7/15/2016

Participating Start Date

10/1/2016

Participating Approval Date

8/16/2016

Last Recertification Date

2/10/2025

Contacts

Authorizing Official

Promise Healthcare Frances Nelson Health Center
Jennifer Henry, Promise Healthcare Executive Director
(217) 403-5401

Primary Contact

Promise Healthcare
Emily McKay, Compliance Specialist and Coordinator
(217) 403-5418

Addresses

Street Address

819 Bloomington Road
Champaign, IL 61820

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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?
Yes

State	Medicaid Number	NPI Number
IL	352788153001,334728248001,537518825001,343882076001,337800584001,353767350001,141880824005,141880824001,141880824004,141880824008,141880824007,141880824006,341803084001,19033190,349583089001,36118017,424085534001,36093780,713853639001,557579302001,19032794,36103204,357841654001	1952894180,1407199391,1629846928,1629828439,1710923560,1811062623,1144662388,1841713450,1851961577,1154932218,1477572733,1043936438,1578821005,1316639537,1043084528,1740038009,1689441099,1942040324

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	HUDSON DRUG SHOP	108 N MARKET ST	PO BOX 70	PAXTON	IL	60957-1220	07/14/2019	10/01/2019		10/01/2019
Contract Detail	INDEPENDENCE HOLDING CO LLC	DBA COMPLETE CARE PHARMACY	14 E WASHINGTON ST. SUITE C	CHAMPAIGN	IL	61820	08/16/2016	10/01/2016	07/30/2019	10/10/2019
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/05/2021	07/01/2021	02/25/2024	02/25/2024
Contract Detail	WAL-MART PHARMACY 10-0813	401 W. COMMERCE		BROWNWOOD	TX	76801	04/06/2022	07/01/2022	04/19/2022	04/25/2022
Contract Detail	WAL-MART PHARMACY 10-1093	845 BROADMEADOW RD		RANTOUL	IL	61866	04/06/2022	07/01/2022	02/25/2024	02/25/2024
Contract Detail	WAL-MART PHARMACY 10-1734	2610 NO PROSPECT AVE		CHAMPAIGN	IL	61821	04/05/2021	07/01/2021	03/30/2023	03/30/2023
Contract Detail	WAL-MART PHARMACY 10-5403	100 SOUTH HIGH CROSS ROAD		URBANA	IL	61802	04/05/2021	07/01/2021	02/25/2024	02/25/2024
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/05/2021	07/01/2021	02/25/2024	02/25/2024
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/10/2023	04/01/2023	02/25/2024	02/25/2024
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/09/2023	01/01/2024	02/25/2024	02/25/2024

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC29834-00	Active	BPS-H80-017987	PROMISE HEALTHCARE NFP	Frances Nelson	819 Bloomington Road	Champaign	IL
CHC29834-01	Active	BPS-H80-035822	PROMISE HEALTHCARE NFP	Promise Healthcare Neil St	821 S Neil St	Champaign	IL
CHC29834-02	Terminated	BPS-H80-017986	PROMISE HEALTHCARE NFP	Promise Healthcare at the Community Resource Center	1400 W. Park, Building #3	Urbana	IL
CHC29834-03	Active	BPS-H80-022072	PROMISE HEALTHCARE NFP	Promise Healthcare at the USBHC	1002 S. Race	Urbana	IL
CHC29834-04	Active	BPS-H80-037455	PROMISE HEALTHCARE	Promise Healthcare - Rantoul	424 E Wabash Ave	Rantoul	IL
CHC29834-05	Active	BPS-H80-038183	PROMISE HEALTHCARE	Promise Healthcare - Kirby	919 West Kirby Avenue	Champaign	IL

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC29834-01	HUDSON DRUG SHOP	108 N MARKET ST	PO BOX 70	PAXTON	IL	60957-1220	10/01/2019
CHC29834-03	HUDSON DRUG SHOP	108 N MARKET ST	PO BOX 70	PAXTON	IL	60957-1220	10/01/2019
CHC29834-02	HUDSON DRUG SHOP	108 N MARKET ST	PO BOX 70	PAXTON	IL	60957-1220	10/01/2019	01/01/2021
CHC29834-00	HUDSON DRUG SHOP	108 N MARKET ST	PO BOX 70	PAXTON	IL	60957-1220	10/01/2019
CHC29834-04	HUDSON DRUG SHOP	108 N MARKET ST	PO BOX 70	PAXTON	IL	60957-1220	04/01/2024
CHC29834-05	HUDSON DRUG SHOP	108 N MARKET ST	PO BOX 70	PAXTON	IL	60957-1220	01/01/2025
CHC29834-00	INDEPENDENCE HOLDING CO LLC	DBA COMPLETE CARE PHARMACY	14 E WASHINGTON ST. SUITE C	CHAMPAIGN	IL	61820	10/01/2016	07/30/2019
CHC29834-01	INDEPENDENCE HOLDING CO LLC	DBA COMPLETE CARE PHARMACY	14 E WASHINGTON ST. SUITE C	CHAMPAIGN	IL	61820	10/01/2016	07/30/2019
CHC29834-02	INDEPENDENCE HOLDING CO LLC	DBA COMPLETE CARE PHARMACY	14 E WASHINGTON ST. SUITE C	CHAMPAIGN	IL	61820	10/01/2016	07/30/2019
CHC29834-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2021	02/25/2024
CHC29834-01	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2021	02/25/2024
CHC29834-03	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2021	02/25/2024
CHC29834-00	WAL-MART PHARMACY 10-0813	401 W. COMMERCE		BROWNWOOD	TX	76801	07/01/2022	04/19/2022
CHC29834-00	WAL-MART PHARMACY 10-1093	845 BROADMEADOW RD		RANTOUL	IL	61866	07/01/2022	02/25/2024
CHC29834-01	WAL-MART PHARMACY 10-1093	845 BROADMEADOW RD		RANTOUL	IL	61866	10/01/2023	02/25/2024
CHC29834-03	WAL-MART PHARMACY 10-1093	845 BROADMEADOW RD		RANTOUL	IL	61866	10/01/2023	02/25/2024
CHC29834-00	WAL-MART PHARMACY 10-1734	2610 NO PROSPECT AVE		CHAMPAIGN	IL	61821	07/01/2021	03/30/2023
CHC29834-01	WAL-MART PHARMACY 10-1734	2610 NO PROSPECT AVE		CHAMPAIGN	IL	61821	07/01/2021	03/31/2023
CHC29834-03	WAL-MART PHARMACY 10-1734	2610 NO PROSPECT AVE		CHAMPAIGN	IL	61821	07/01/2021	03/31/2023
CHC29834-01	WAL-MART PHARMACY 10-5403	100 SOUTH HIGH CROSS ROAD		URBANA	IL	61802	07/01/2021	02/25/2024
CHC29834-00	WAL-MART PHARMACY 10-5403	100 SOUTH HIGH CROSS ROAD		URBANA	IL	61802	07/01/2021	02/25/2024
CHC29834-03	WAL-MART PHARMACY 10-5403	100 SOUTH HIGH CROSS ROAD		URBANA	IL	61802	07/01/2021	02/25/2024
CHC29834-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2021	02/25/2024
CHC29834-01	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2021	02/25/2024
CHC29834-03	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/01/2021	02/25/2024
CHC29834-00	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023	02/25/2024
CHC29834-01	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023	02/25/2024
CHC29834-03	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023	02/25/2024
CHC29834-01	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024	02/25/2024
CHC29834-03	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024	02/25/2024
CHC29834-00	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024	02/25/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Recertification	35804165001 (IL)		2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	036118017 (IL)		2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	036103204 (IL)		2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	036052572 (IL)		2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	019032794 (IL)		2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	019033190 (IL)		2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	360781191001 (IL)		2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		19033190	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		349583089001	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		36118017	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		424085534001	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		36093780	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		713853639001	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		557579302001	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		19032794	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		36103204	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		357841654001	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1255833695 (IL)		2/10/2025 12:02 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1851051221 (IL)		2/10/2025 12:02 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1215952684 (IL)		2/10/2025 12:02 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1093351413 (IL)		2/10/2025 12:02 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1689441099	2/10/2025 12:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1942040324	2/10/2025 12:02 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	2/10/2025 12:02 PM
Details	Last Recertification Date	Update	Recertification	1/29/2024 9:30:36 AM	2/10/2025 12:02:26 PM	2/10/2025 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	19033190 (IL)		10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	36118017 (IL)		10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	308966363001 (IL)		10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	19032794 (IL)		10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	340581276001 (IL)		10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	36103204 (IL)		10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	36052572 (IL)		10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		141880824008	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		141880824007	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		141880824006	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		036118017	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		036103204	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		036052572	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		019032794	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		019033190	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		341803084001	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		360781191001	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1073938882 (IL)		10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1073183646 (IL)		10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1700281342 (IL)		10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1043936438	10/10/2024 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1578821005	10/10/2024 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316639537	10/10/2024 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1043084528	10/10/2024 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1740038009	10/10/2024 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1093351413	10/10/2024 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/10/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/9/2024 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		141880824004	4/9/2024 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/9/2024 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		141880824005	4/3/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		141880824001	4/3/2024 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 2:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		35804165001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		19033190	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		352788153001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		36118017	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		334728248001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		537518825001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		343882076001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		308966363001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		337800584001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		19032794	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		340581276001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		36103204	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		353767350001	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		36052572	4/3/2024 1:29 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952894180	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073938882	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1407199391	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629846928	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629828439	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1710923560	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1255833695	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1811062623	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851051221	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1144662388	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1841713450	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1073183646	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700281342	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1851961577	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154932218	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1477572733	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1215952684	4/3/2024 1:29 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/3/2024 1:29 PM
Details	Last Recertification Date	Update	Recertification	1/30/2023 12:25:12 PM	1/29/2024 9:30:36 AM	1/29/2024 9:30 AM
Details	Last Recertification Date	Update	Recertification	1/31/2022 10:25:53 AM	1/30/2023 12:25:12 PM	1/30/2023 12:25 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	141880824001 (IL)		4/29/2022 9:16 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1578821005 (IL)		4/29/2022 9:16 AM
Contacts	Primary Contact	Update	PC Change Request	Bradley, April 340B and Medication Assistance Program Coordinator Frances Nelson Health Center 2173561558-236	McKay, Emily Compliance Specialist and Coordinator Promise Healthcare 2174035418	4/6/2022 11:04 AM
Details	Last Recertification Date	Update	Recertification	2/4/2021 2:33:31 PM	1/31/2022 10:25:53 AM	1/31/2022 10:25 AM
Contacts	Primary Contact	Update	Change Request	Owens, Pat Director of Finance and Information Promise Healthcare 2174035473	Bradley, April 340B and Medication Assistance Program Coordinator Frances Nelson Health Center 2173561558-236	1/11/2022 8:04 AM
Contacts	Authorizing Official	Update	Change Request	Bradley, April 340B and Medication Assistance Program Coordinator Frances Nelson Health Center 2173561558-236	Henry, Jennifer Promise Healthcare Executive Director Promise Healthcare Frances Nelson Health Center 2174035401	1/11/2022 8:04 AM
Contacts	Authorizing Official	Update	Change Request	Bradley, April 340B and Medication Assistance Program Coordinator Frances Nelson Health Center 2173561558	Bradley, April 340B and Medication Assistance Program Coordinator Frances Nelson Health Center 2173561558-236	1/10/2022 1:19 PM
Contacts	Authorizing Official	Update	AO Change Request	Lamb, Deanna Interim Chief Executive Officer Promise Healthcare 9106246289	Bradley, April 340B and Medication Assistance Program Coordinator Frances Nelson Health Center 2173561558	11/24/2021 7:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1578821005	2/4/2021 2:33 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	2/4/2021 2:33 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1578821005 ( )		2/4/2021 2:33 PM
Details	Last Recertification Date	Update	Recertification	1/29/2020 10:41:34 AM	2/4/2021 2:33:31 PM	2/4/2021 2:33 PM
Details	Is Authorizing Official EHB Data	Update	Recertification	False		2/4/2021 2:33 PM
Contacts	Authorizing Official	Update	AO Change Request	Greenwalt, Nancy Executive Director Promise Healthcare 2174035401	Lamb, Deanna Interim Chief Executive Officer Promise Healthcare 9106246289	1/26/2021 4:20 PM
Details	Last Recertification Date	Update	Recertification	2/1/2019 8:21:57 AM	1/29/2020 10:41:34 AM	1/29/2020 10:41 AM
Details	Last Recertification Date	Update	Recertification	2/12/2018 5:03:30 PM	2/1/2019 8:21:57 AM	2/1/2019 8:21 AM
Details	Last Recertification Date	Update	Recertification	2/17/2017 12:00:00 AM	2/12/2018 5:03:30 PM	2/12/2018 5:03 PM
Contacts	Authorizing Official	Update		Greenwalt, Nancy Executive Director 2174035401	Greenwalt, Nancy Executive Director Promise Healthcare 2174035401	2/12/2018 4:59 PM
Contacts	Signed By	Update		Greenwalt, Nancy Executive Director 2174035401	Greenwalt, Nancy Executive Director Promise Healthcare 2174035401	2/12/2018 4:59 PM
Contacts	Primary Contact	Update		Owens, Pat Director of Finance and Information 2174035473	Owens, Pat Director of Finance and Information Promise Healthcare 2174035473	9/29/2017 9:24 AM
Contacts	Authorizing Official	Insert			Greenwalt, Nancy Executive Director 2174035401	5/9/2017 3:53 PM
Contacts	Signed By	Insert			Greenwalt, Nancy Executive Director 2174035401	5/9/2017 3:53 PM
Contacts	Primary Contact	Insert			Owens, Pat Director of Finance and Information 2174035473	5/9/2017 3:53 PM
Addresses	Main Address	Insert			819 Bloomington Road Champaign, IL 61820	2/17/2017 3:14 PM
Details	Last Recertification Date	Update			2/17/2017 12:00:00 AM	2/17/2017 3:14 PM
Dates	Participating Approval Date	Update			8/16/2016 12:00:00 AM	8/16/2016 3:06 PM
Details	State	Update		Pending	Active	8/16/2016 3:06 PM
Dates	Start Date	Update			10/1/2016 12:00:00 AM	8/16/2016 3:06 PM
Details	340B ID	Update		ONLINE_REG_72095	CHC29834-00	7/18/2016 1:50 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_72095	7/15/2016 5:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/15/2016 5:02 PM
Medicaid Billing	Medicaid: Number	Insert			141880824001	7/15/2016 5:02 PM
Medicaid Billing	Medicaid: State	Insert			IL	7/15/2016 5:02 PM
Medicaid Billing	NPI: Number	Insert			1578821005	7/15/2016 5:02 PM
Details	Last Recertification Date	Insert				7/15/2016 5:02 PM
Details	Grant Number	Insert			H80CS29834	7/15/2016 5:02 PM
Details	340B ID	Insert			ONLINE_REG	7/15/2016 5:02 PM
Details	Is Authorizing Official EHB Data	Insert			False	7/15/2016 5:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/15/2016 5:02 PM
Details	Medicare Provider Number	Insert				7/15/2016 5:02 PM
Details	Entity Name	Insert			PROMISE HEALTHCARE NFP	7/15/2016 5:02 PM
Details	Program Code	Insert			CH	7/15/2016 5:02 PM
Details	Entity Subname	Insert			Frances Nelson	7/15/2016 5:02 PM
Dates	Participating Approval Date	Insert				7/15/2016 5:02 PM
Details	State	Insert			Pending	7/15/2016 5:02 PM
Dates	Registration Date	Insert			7/15/2016 12:00:00 AM	7/15/2016 5:02 PM
Dates	Signed By Date	Insert			7/15/2016 12:00:00 AM	7/15/2016 5:02 PM
Dates	Start Date	Insert				7/15/2016 5:02 PM
Terminations	Termination Comments	Insert				7/15/2016 5:02 PM
Terminations	Termination Date	Insert				7/15/2016 5:02 PM
Terminations	Termination Effective Date	Insert				7/15/2016 5:02 PM
Terminations	Termination Reason	Insert				7/15/2016 5:02 PM

340B Drug Pricing Program Database