Covered Entity Details

DSH140054 MACNEAL HOSPITAL (Active) - information as of 5/6/2025 11:05:54 PM

Main Details

Name

MACNEAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH140054

Medicare Provider Number

140054

Additional Details

Current Program Status

Active

Registration Date

10/24/2018

Participating Start Date

1/1/2019

Participating Approval Date

11/5/2018

Last Recertification Date

9/10/2024

Contacts

Authorizing Official

Loyola Medicine
Melissa M. Lukasick, CFO Illinois Region
(708) 216-5723

Primary Contact

Loyola Medicine
Zohra Saleem, Regional 340B Manager
(708) 216-3875

Addresses

Street Address

3249 SOUTH OAK PARK AVENUE
BERWYN, IL 60402

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 10/1/2018; terminated 10/1/2018; Reinstated 1/1/2019.	11/01/2018

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	363332852001,363332852002,363332852003	1295710580,1932870573

Shipping Addresses

Shipping Address 1

Gottlieb Community Health Services Corportaion
DBA: MacNeal Outpatient Pharmacy
3249 S Oak Park Avenue
T1201
Berwyn, IL 60402

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	AVELLA OF ORLANDO	100 TECHNOLOGY PARK STE 155		LAKE MARY	FL	32746-6205	01/28/2020	04/01/2020	03/02/2020	03/04/2020
Contract Detail	AVELLA OF ORLANDO	100 TECHNOLOGY PARK STE 155		LAKE MARY	FL	32746-6205	04/09/2020	07/01/2020	04/13/2022	04/13/2022
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02711	7150 W ARCHER AVE	CHICAGO	IL	60638	11/05/2018	01/01/2019		01/01/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02785	5840 WEST 35TH ST	CICERO	IL	60804	11/05/2018	01/01/2019		01/01/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #11492	5414 S. ARCHER AVE	CHICAGO	IL	60638-3002	11/05/2018	01/01/2019		01/01/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05234	5435 S KEDZIE AVE	CHICAGO	IL	60632	11/05/2018	01/01/2019		01/01/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05103	5932 W. CERMAK RD	CICERO	IL	60804	11/05/2018	01/01/2019		01/01/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05235	6412 ROOSEVELT RD	OAK PARK	IL	60304-2135	11/05/2018	01/01/2019		01/01/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05076	6800 OGDEN AVE	BERWYN	IL	60402	11/05/2018	01/01/2019		01/01/2019
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04009	4730 BUTTERFIELD ROAD	HILLSIDE	IL	60162	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04148	7960 W. 159TH ST.	ORLAND PARK	IL	60462	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04233	5600 W. FULLERTON	CHICAGO	IL	60639	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05034	6315 S KEDZIE AVE	CHICAGO	IL	60629	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01417	1931 W CERMAK RD	CHICAGO	IL	60608	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05139	7945 W 95TH ST	HICKORY HILLS	IL	60457	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #11760	811 MADISON ST	OAK PARK	IL	60302	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03960	7200 ROOSEVELT RD	FOREST PARK	IL	60130	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03833	2828 N HARLEM	ELMWOOD PARK	IL	60707	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01503	1926 W 35TH ST	CHICAGO	IL	60609	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS #15080	5555 WEST 79TH ST	BURBANK	IL	60459	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05149	1600 W. ROOSEVELT RD	BROADVIEW	IL	60155	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04874	6600 WILLOW SPRINGS RD	LA GRANGE HIGHLANDS	IL	60525	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03076	7251 LAKE STREET	RIVER FOREST	IL	60305	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03995	6 E NORTH AVE	NORTHLAKE	IL	60164	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04664	10345 W ROOSEVELT ROAD	WESTCHESTER	IL	60154	10/14/2019	01/01/2020		01/01/2020
Contract Detail	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03779	100 LAKE ST	MAYWOOD	IL	60153	10/14/2019	01/01/2020		01/01/2020
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/12/2021	07/01/2021		07/01/2021
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/12/2021	07/01/2021		07/01/2021
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	11/05/2018	01/01/2019		01/01/2019
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08741	2634 S PULASKI	CHICAGO	IL	60623	04/17/2020	07/01/2020	03/14/2024	03/21/2024
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 03889	7929 NORTH AVE.	RIVER FOREST	IL	60305	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16287	9250 JOLIET RD	HODGKINS	IL	60525	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 07134	1400 E. ROOSEVELT RD.	WHEATON	IL	60187	04/17/2020	07/01/2020	03/14/2024	03/21/2024
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16999	4433 S PULASKI RD	CHICAGO	IL	60632	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 16219	2901 S CICERO AVE	CICERO	IL	60804	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02827	600 NORTH MANNHEIM RD.	HILLSIDE	IL	60162	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08744	9139 BROADWAY	BROOKFIELD	IL	60513	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08736	7216 CIRCLE AVE	FOREST PARK	IL	60130	04/17/2020	07/01/2020	08/13/2021	04/13/2022
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 02844	6748 ROOSEVELT RD.	OAK PARK	IL	60304	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17169	800 BROADVIEW VILLAGE SQ	BROADVIEW	IL	60155	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 05213	8911 OGDEN AVE.	BROOKFIELD	IL	60513	04/17/2020	07/01/2020	03/14/2024	03/21/2024
Contract Detail	HIGHLAND PARK CVS, L.L.C.	CVS PHARMACY # 17536	130 S MANNHEIM RD	HILLSIDE	IL	60162	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 03163	345 MADISON ST.	OAK PARK	IL	60302	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 08742	5524 W CERMAK RD, STE 1	CICERO	IL	60804	04/17/2020	07/01/2020		07/01/2020
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA CVS/PHARMACY # 1965	7200 W. CERMAK RD.	NORTH RIVERSIDE	IL	60546	04/17/2020	07/01/2020	03/14/2024	03/21/2024
Contract Detail	LOYOLA UNIVERSITY MEDICAL CENTER	9608 S ROBERTS RD		HICKORY HILLS	IL	60457-2238	04/09/2020	07/01/2020		07/01/2020
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	07/08/2020	10/01/2020		10/01/2020
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	01/28/2020	04/01/2020	03/02/2020	03/04/2020
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	04/09/2020	07/01/2020	04/13/2022	04/18/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/28/2020	04/01/2020	03/02/2020	03/04/2020
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/09/2020	07/01/2020		07/01/2020
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	01/28/2020	04/01/2020	03/02/2020	03/04/2020
Contract Detail	OPTUM PHARMACY 705, LLC	11142 RENNER BLVD		LENEXA	KS	66219	01/28/2020	04/01/2020	03/02/2020	03/04/2020
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/09/2020	07/01/2020		07/01/2020
Contract Detail	OPTUM PHARMACY 705, LLC	11142 RENNER BLVD		LENEXA	KS	66219	04/09/2020	07/01/2020	04/13/2022	04/13/2022
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	01/28/2020	04/01/2020	03/02/2020	03/04/2020
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/09/2020	07/01/2020		07/01/2020
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	11/05/2018	01/01/2019	10/01/2022	11/04/2022
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	07/08/2020	10/01/2020		10/01/2020
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	07/08/2020	10/01/2020		10/01/2020
Contract Detail	SINA DRUG LLC	DBA ONCO360	7125 JANES AVE STE 700	WOODRIDGE	IL	60517	12/17/2020	12/17/2020		12/17/2020
Contract Detail	SORKIN'S RX LTD	D/B/A CAREMED PHARMACEUTICAL SERVICES	1985 MARCUS AVE STE 130	NEW HYDE PARK	NY	11042-2024	07/08/2020	10/01/2020		10/01/2020
Contract Detail	Trinity Health Pharmacy Services, LLC	12279 Bluffton Road		Fort Waye	IN	46809	10/14/2019	01/01/2020		04/14/2023
Contract Detail	WALGREEN CO	DBA: WALGREENS #15525	201 E. HURON STREET, SUITE 01-210	CHICAGO	IL	60611	10/14/2019	01/01/2020		01/01/2020
Contract Detail	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	01/16/2023	04/01/2023		04/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 11154	7113 CERMAK RD	BERWYN	IL	60402	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06297	6016 W 63RD STREET	CHICAGO	IL	60638-4318	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03321	5874 S ARCHER AVENUE	CHICAGO	IL	60638-1645	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00226	4005 W 26TH STREET	CHICAGO	IL	60623	11/05/2018	01/01/2019	02/18/2025	04/15/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01450	4101 1ST AVE	LYONS	IL	60534	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13966	3249 S. OAK PARK AVE STE T1201	BERWYN	IL	60402	11/05/2018	01/01/2019	09/21/2020	10/12/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06427	7878 S HARLEM AVE	BRIDGEVIEW	IL	60455	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01449	8000 BROADVIEW VILLAGE SQUARE	BROADVIEW	IL	60155-2601	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01249	4800 W CERMAK RD	CICERO	IL	60804	11/05/2018	01/01/2019	11/06/2024	04/15/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 13826	7200 W. NORTH AVE.	ELMWOOD PARK	IL	60707	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03710	15575 E 127TH STREET	LEMONT	IL	60439	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05867	3943 W 47TH STREET	CHICAGO	IL	60632-4145	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00163	4000 W 59TH ST	CHICAGO	IL	60629	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00215	3045 W 26TH STREET	CHICAGO	IL	60623	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05713	4740 W. 95TH STREET	OAK LAWN	IL	60453	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06563	498 N WEBER ROAD	ROMEOVILLE	IL	60446	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS #16093	3040 S. CICERO AVE. SUITE A	CICERO	IL	60804	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05670	2 N LA GRANGE RD	LA GRANGE	IL	60525	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05724	7045 S PULASKI ROAD	CHICAGO	IL	60629-5833	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09033	7516 S CASS AVE STE 1	DARIEN	IL	60561	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06046	2151 S WOLF RD	HILLSIDE	IL	60162	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05926	4385 S ARCHER AVE	CHICAGO	IL	60632	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06462	9595 GRAND AVE	FRANKLIN PARK	IL	60131	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00089	8715 S HARLEM AVE	BRIDGEVIEW	IL	60455	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05684	8800 W 95TH ST	HICKORY HILLS	IL	60457	10/14/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15506	3303 W. 26TH STREET SUITE 101	CHICAGO	IL	60623	01/16/2023	04/01/2023		04/01/2023
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	11/05/2018	01/01/2019		01/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	11/05/2018	01/01/2019	10/11/2021	11/05/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH140054A	Child	DSH	MACNEAL HOSPITAL	Family Practice IM -PC-MacNeal	3722 HARLEM AVE LL34	RIVERSIDE	IL	Active
DSH140054B	Child	DSH	MACNEAL HOSPITAL	VHS OF ILLINOIS INC - LaGrange Immediate Care	125 N LA GRANGE RD	LA GRANGE	IL	Terminated
DSH140054C	Child	DSH	MACNEAL HOSPITAL	BERWYN MAGNETIC RESONANCE CENTER - MRI	3345 OAK PARK AVE	BERWYN	IL	Terminated
DSH140054D	Child	DSH	MACNEAL HOSPITAL	Family Practice -PC-MacNeal	3231 EUCLID AVE 5TH FLR	BERWYN	IL	Active
DSH140054E	Child	DSH	MACNEAL HOSPITAL	MACNEAL PAIN CENTER - Pain Clinic	2550 SOUTH OAK PARK AVE	Berwyn	IL	Terminated
DSH140054F	Child	DSH	MACNEAL HOSPITAL	MACNEAL HOSP CTR FOR CANCER CARE - Cancer Center Oncology-Berwyn	6801 34TH ST	BERWYN	IL	Active
DSH140054G	Child	DSH	MACNEAL HOSPITAL	MACNEAL OUTPATIENT IMAGING - Outpatient Imaging	3722 HARLEM AVE	RIVERSIDE	IL	Terminated
DSH140054H	Child	DSH	MACNEAL HOSPITAL	MACNEAL WOUND CARE - Wound Care Suite 100	3722 HARLEM AVE	RIVERSIDE	IL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/7/2023 6:46:35 AM	9/10/2024 11:55:10 AM	9/10/2024 11:55 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 1:21:10 PM	9/7/2023 6:46:35 AM	9/7/2023 6:46 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 10:52:05 AM	8/29/2022 1:21:10 PM	8/29/2022 1:21 PM
Contacts	Primary Contact	Update	Change Request	Vadakara, Joe Regional Pharmacy Director Loyola Medicine 7082160399	Saleem, Zohra Regional 340B Manager Loyola Medicine 7082163875	7/13/2022 7:39 AM
Contacts	Authorizing Official	Update	Change Request	Isacksen, Daniel Paul EVP and Regional CFO Loyola University Medical Center 7082164252	Lukasick, Melissa M. CFO Illinois Region Loyola Medicine 7082165723	2/4/2022 11:29 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1932870573	11/24/2021 7:03 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	11/24/2021 7:03 AM
Addresses	Shipping Address	Insert	Change Request		Gottlieb Community Health Services Corportaion DBA: MacNeal Outpatient Pharmacy 3249 S Oak Park Avenue T1201 Berwyn, IL 60402	11/5/2021 11:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1235117888 (IL)		9/10/2021 10:52 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1700864352 (IL)		9/10/2021 10:52 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1871977751 (IL)		9/10/2021 10:52 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 2:27:30 PM	9/10/2021 10:52:05 AM	9/10/2021 10:52 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1295710580 ( )		9/11/2020 2:27 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1700864352 ( )		9/11/2020 2:27 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1871977751 ( )		9/11/2020 2:27 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1235117888	9/11/2020 2:27 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:27 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1295710580	9/11/2020 2:27 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:27 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1700864352	9/11/2020 2:27 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:27 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1871977751	9/11/2020 2:27 PM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/11/2020 2:27 PM
Details	Last Recertification Date	Update	Recertification	9/10/2019 8:43:59 AM	9/11/2020 2:27:30 PM	9/11/2020 2:27 PM
Contacts	Primary Contact	Update	Profile Change Request	Vadakara, Joe Pharmacy Director Loyola University 7087832318	Vadakara, Joe Regional Pharmacy Director Loyola Medicine 7082160399	4/8/2020 5:34 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		363332852001	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		363332852002	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		363332852003	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	621796152001 (IL)		3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	621796152401 (IL)		3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	621796152012 (IL)		3/4/2020 4:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	621796152013 (IL)		3/4/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1295710580	3/4/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1700864352	3/4/2020 4:10 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871977751	3/4/2020 4:10 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1235117888 ( )		3/4/2020 4:10 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1295710580 ( )		3/4/2020 4:10 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1871977751 ( )		3/4/2020 4:10 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1700864352 ( )		3/4/2020 4:10 PM
Contacts	Authorizing Official	Update	Change Request	Post, Daniel Executive Vice President Loyola University Medical Center 7082161670	Isacksen, Daniel Paul EVP and Regional CFO Loyola University Medical Center 7082164252	1/28/2020 8:56 AM
Details	Last Recertification Date	Update	Recertification		9/10/2019 8:43:59 AM	9/10/2019 8:43 AM
Contacts	Primary Contact	Update	Change Request	Pong, William Administrative Director, Pharmacy Services Loyola University Medical Center 7082160399	Vadakara, Joe Pharmacy Director Loyola University 7087832318	6/13/2019 4:01 PM
Contacts	Primary Contact	Update	Change Request	Pong, William Administrative Director, Pharmacy Services MacNeal Hospital 7082160399	Pong, William Administrative Director, Pharmacy Services Loyola University Medical Center 7082160399	3/25/2019 1:04 PM
Details	State	Update		Approved	Active	1/1/2019 12:05 AM
Dates	Participating Approval Date	Update	Reinstatement		11/5/2018 2:48:40 PM	11/5/2018 2:48 PM
Details	State	Update	Reinstatement	Pending	Approved	11/5/2018 2:48 PM
Dates	Signed By Date	Update	Reinstatement	7/13/2018 1:24:51 PM	10/26/2018 1:27:00 PM	11/5/2018 2:48 PM
Dates	Start Date	Update	Reinstatement		1/1/2019 12:00:00 AM	11/5/2018 2:48 PM
Details	Comments Public	Insert	Reinstatement		Participated starting 10/1/2018; terminated 10/1/2018; Reinstated 1/1/2019.	11/1/2018 11:32 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	9/26/2018 12:00:00 AM		10/24/2018 4:15 PM
Dates	Participating Approval Date	Update	Reinstatement	7/17/2018 10:53:52 AM		10/24/2018 4:15 PM
Details	State	Update	Reinstatement	Terminated	Pending	10/24/2018 4:15 PM
Dates	Registration Date	Update	Reinstatement	7/9/2018 10:50:12 AM	10/24/2018 4:15:09 PM	10/24/2018 4:15 PM
Dates	Start Date	Update	Reinstatement	10/1/2018 12:00:00 AM		10/24/2018 4:15 PM
Terminations	Termination Comments	Update	Reinstatement	Delayed in split billing software implementation so therefore cannot go live on Oct 1st, 2018. No 340b drugs purchased.		10/24/2018 4:15 PM
Terminations	Termination Date	Update	Reinstatement	10/1/2018 12:00:00 AM		10/24/2018 4:15 PM
Terminations	Termination Effective Date	Update	Reinstatement	9/26/2018 12:00:00 AM		10/24/2018 4:15 PM
Terminations	Termination Reason	Update	Reinstatement	Other		10/24/2018 4:15 PM
Dates	Last Date That 340B Drugs Purchased	Update			9/26/2018 12:00:00 AM	10/24/2018 8:38 AM
Dates	Participating Approval Date	Update			7/17/2018 10:53:52 AM	10/24/2018 8:38 AM
Details	State	Update		Pending	Terminated	10/24/2018 8:38 AM
Dates	Registration Date	Update		10/5/2018 4:20:22 PM	7/9/2018 10:50:12 AM	10/24/2018 8:38 AM
Dates	Start Date	Update			10/1/2018 12:00:00 AM	10/24/2018 8:38 AM
Terminations	Termination Comments	Update			Delayed in split billing software implementation so therefore cannot go live on Oct 1st, 2018. No 340b drugs purchased.	10/24/2018 8:38 AM
Terminations	Termination Date	Update			10/1/2018 12:00:00 AM	10/24/2018 8:38 AM
Terminations	Termination Effective Date	Update			9/26/2018 12:00:00 AM	10/24/2018 8:38 AM
Terminations	Termination Reason	Update			Other	10/24/2018 8:38 AM
Dates	Last Date That 340B Drugs Purchased	Update		9/26/2018 12:00:00 AM		10/5/2018 4:20 PM
Dates	Participating Approval Date	Update		7/17/2018 10:53:52 AM		10/5/2018 4:20 PM
Details	State	Update		Terminated	Pending	10/5/2018 4:20 PM
Dates	Registration Date	Update		7/9/2018 10:50:12 AM	10/5/2018 4:20:22 PM	10/5/2018 4:20 PM
Dates	Start Date	Update		10/1/2018 12:00:00 AM		10/5/2018 4:20 PM
Terminations	Termination Comments	Update		Delayed in split billing software implementation so therefore cannot go live on Oct 1st, 2018. No 340b drugs purchased.		10/5/2018 4:20 PM
Terminations	Termination Date	Update		10/1/2018 12:00:00 AM		10/5/2018 4:20 PM
Terminations	Termination Effective Date	Update		9/26/2018 12:00:00 AM		10/5/2018 4:20 PM
Terminations	Termination Reason	Update		Other		10/5/2018 4:20 PM
Details	State	Update		To Be Terminated	Terminated	10/1/2018 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		9/26/2018 12:00:00 AM	9/27/2018 2:05 PM
Details	State	Update	Termination Request	Approved	To Be Terminated	9/27/2018 2:05 PM
Terminations	Termination Comments	Update	Termination Request		Delayed in split billing software implementation so therefore cannot go live on Oct 1st, 2018. No 340b drugs purchased.	9/27/2018 2:05 PM
Terminations	Termination Date	Update	Termination Request		10/1/2018 12:00:00 AM	9/27/2018 2:05 PM
Terminations	Termination Effective Date	Update	Termination Request		9/26/2018 12:00:00 AM	9/27/2018 2:05 PM
Terminations	Termination Reason	Update	Termination Request		Other	9/27/2018 2:05 PM
Contacts	Signed By	Insert	New Registration		Post, Daniel Executive Vice President Loyola University Medical Center 7082161670	7/17/2018 10:53 AM
Details	340B ID	Update	New Registration		DSH140054	7/17/2018 10:53 AM
Dates	Participating Approval Date	Update	New Registration		7/17/2018 10:53:52 AM	7/17/2018 10:53 AM
Details	State	Update	New Registration	Pending	Approved	7/17/2018 10:53 AM
Dates	Signed By Date	Update	New Registration		7/13/2018 1:24:51 PM	7/17/2018 10:53 AM
Dates	Start Date	Update	New Registration		10/1/2018 12:00:00 AM	7/17/2018 10:53 AM
Addresses	Main Address	Insert	New Registration		3249 SOUTH OAK PARK AVENUE BERWYN, IL 60402	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		621796152001	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		621796152401	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		621796152012	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		621796152013	7/9/2018 10:50 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	7/9/2018 10:50 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1235117888	7/9/2018 10:50 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295710580	7/9/2018 10:50 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1871977751	7/9/2018 10:50 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1700864352	7/9/2018 10:50 AM
Contacts	Primary Contact	Insert	New Registration		Pong, William Administrative Director, Pharmacy Services MacNeal Hospital 7082160399	7/9/2018 10:50 AM
Contacts	Authorizing Official	Insert	New Registration		Post, Daniel Executive Vice President Loyola University Medical Center 7082161670	7/9/2018 10:50 AM
Details	Last Recertification Date	Insert	New Registration			7/9/2018 10:50 AM
Details	Grant Number	Insert	New Registration			7/9/2018 10:50 AM
Details	340B ID	Insert	New Registration			7/9/2018 10:50 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/9/2018 10:50 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/9/2018 10:50 AM
Details	Medicare Provider Number	Insert	New Registration		140054	7/9/2018 10:50 AM
Details	Entity Name	Insert	New Registration		MACNEAL HOSPITAL	7/9/2018 10:50 AM
Details	Program Code	Insert	New Registration		DSH	7/9/2018 10:50 AM
Details	Entity Subname	Insert	New Registration			7/9/2018 10:50 AM
Dates	Participating Approval Date	Insert	New Registration			7/9/2018 10:50 AM
Details	State	Insert	New Registration		Pending	7/9/2018 10:50 AM
Dates	Registration Date	Insert	New Registration		7/9/2018 10:50:12 AM	7/9/2018 10:50 AM
Dates	Signed By Date	Insert	New Registration			7/9/2018 10:50 AM
Dates	Start Date	Insert	New Registration			7/9/2018 10:50 AM
Terminations	Termination Comments	Insert	New Registration			7/9/2018 10:50 AM
Terminations	Termination Date	Insert	New Registration			7/9/2018 10:50 AM
Terminations	Termination Effective Date	Insert	New Registration			7/9/2018 10:50 AM
Terminations	Termination Reason	Insert	New Registration			7/9/2018 10:50 AM