| Details | Last Recertification Date | Update | Recertification | 2/7/2024 2:02:25 PM | 2/21/2025 1:48:39 PM | 2/21/2025 1:48 PM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2023 11:27:57 AM | 2/7/2024 2:02:25 PM | 2/7/2024 2:02 PM |
| Details | Last Recertification Date | Update | Recertification | 2/25/2022 10:04:04 AM | 2/3/2023 11:27:57 AM | 2/3/2023 11:27 AM |
| Details | Last Recertification Date | Update | Recertification | 2/4/2021 4:20:55 PM | 2/25/2022 10:04:04 AM | 2/25/2022 10:04 AM |
| Contacts | Primary Contact | Update | Change Request | Schultz, Michael Brian
Pharmacy Director
Lac Vieux Desert Health Center and Pharmacy
9063584905 | Friedley, Dani
Pharmacy Manager
Lac Vieux Desert Health Center
9063584905 | 5/24/2021 10:40 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/4/2021 4:20 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 100095956 | 2/4/2021 4:20 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | WI | 2/4/2021 4:20 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1760536007 ( ) | | 2/4/2021 4:20 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1760536007 | 2/4/2021 4:20 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | WI | 2/4/2021 4:20 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1760536007 | 2/4/2021 4:20 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | MI | 2/4/2021 4:20 PM |
| Details | Last Recertification Date | Update | Recertification | 2/20/2020 11:18:52 AM | 2/4/2021 4:20:55 PM | 2/4/2021 4:20 PM |
| Contacts | Primary Contact | Update | Recertification | MOILANEN, REGAN PATRICIA
PHARMACY TECHNICIAN
LAC VIEUX DESERT PHARMACY
9063584905 | Schultz, Michael Brian
Pharmacy Director
Lac Vieux Desert Health Center and Pharmacy
9063584905 | 2/20/2020 11:18 AM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2019 9:43:05 AM | 2/20/2020 11:18:52 AM | 2/20/2020 11:18 AM |
| Contacts | Authorizing Official | Update | AO Change Request | IVEY, KIM MARIE
PHARMACY MANAGER
Lac Vieux Desert Health Clinic and Pharmacy
9063584905 | Valliere, Sadie
Health Director
Lac Vieux Desert Health Center and Pharmacy
9063584588-6142 | 2/20/2020 10:01 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | IVEY, KIM
PHARMACY MANAGER
Lac Vieux Desert Health Clinic and Pharmacy
9063584905 | IVEY, KIM MARIE
PHARMACY MANAGER
Lac Vieux Desert Health Clinic and Pharmacy
9063584905 | 1/29/2019 10:07 AM |
| Details | Last Recertification Date | Update | Recertification | 2/15/2018 10:00:22 AM | 1/29/2019 9:43:05 AM | 1/29/2019 9:43 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | IVEY, KIM
PHARMACIST
Lac Vieux Desert Pharmacy
9063584905 | IVEY, KIM
PHARMACY MANAGER
Lac Vieux Desert Health Clinic and Pharmacy
9063584905 | 1/29/2019 9:38 AM |
| Contacts | Primary Contact | Update | Recertification | IVEY, KIM
PHARMACIST
Lac Vieux Desert Pharmacy
9063584905 | MOILANEN, REGAN PATRICIA
PHARMACY TECHNICIAN
LAC VIEUX DESERT PHARMACY
9063584905 | 2/15/2018 10:00 AM |
| Details | Last Recertification Date | Update | Recertification | 1/25/2017 12:00:00 AM | 2/15/2018 10:00:22 AM | 2/15/2018 10:00 AM |
| Contacts | Authorizing Official | Update | | IVEY, KIM
PHARMACIST
9063584905 | IVEY, KIM
PHARMACIST
Lac Vieux Desert Pharmacy
9063584905 | 10/3/2017 11:53 AM |
| Contacts | Primary Contact | Update | | IVEY, KIM
PHARMACIST
9063584905 | IVEY, KIM
PHARMACIST
Lac Vieux Desert Pharmacy
9063584905 | 10/3/2017 11:53 AM |
| Addresses | Main Address | Insert | | |
N5241 US HWY 45
WATERSMEET, MI 49969 | 1/25/2017 11:41 AM |
| Contacts | Authorizing Official | Insert | | | IVEY, KIM
PHARMACIST
9063584905 | 1/25/2017 11:41 AM |
| Contacts | Primary Contact | Insert | | | IVEY, KIM
PHARMACIST
9063584905 | 1/25/2017 11:41 AM |
| Medicaid Billing | Medicaid: Number | Update | | 3140293 | 3154459 | 1/25/2017 11:41 AM |
| Details | Last Recertification Date | Update | | 2/23/2016 12:00:00 AM | 1/25/2017 12:00:00 AM | 1/25/2017 11:41 AM |
| Medicaid Billing | Medicaid: Is Primary | Update | | True | False | 2/23/2016 3:58 PM |
| Details | Last Recertification Date | Update | | 1/30/2015 12:00:00 AM | 2/23/2016 12:00:00 AM | 2/23/2016 3:58 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1760536007 | 1/30/2015 4:17 PM |
| Details | Last Recertification Date | Update | | 3/11/2014 12:00:00 AM | 1/30/2015 12:00:00 AM | 1/30/2015 4:17 PM |
| Details | Last Recertification Date | Update | | 4/1/2013 12:00:00 AM | 3/11/2014 12:00:00 AM | 3/11/2014 3:22 PM |
| Details | Last Recertification Date | Update | | | 4/1/2013 12:00:00 AM | 2/22/2013 2:19 PM |
| Details | Last Recertification Date | Insert | | | | 9/14/2007 4:38 PM |
| Details | Grant Number | Insert | | | | 9/14/2007 4:38 PM |
| Details | 340B ID | Insert | | | FQHC638156 | 9/14/2007 4:38 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 9/14/2007 4:38 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 9/14/2007 4:38 PM |
| Details | Medicare Provider Number | Insert | | | | 9/14/2007 4:38 PM |
| Details | Entity Name | Insert | | | LAC VIEUX DESERT BAND | 9/14/2007 4:38 PM |
| Details | Program Code | Insert | | | FQHC638 | 9/14/2007 4:38 PM |
| Details | Entity Subname | Insert | | | | 9/14/2007 4:38 PM |
| Dates | Participating Approval Date | Insert | | | 10/1/1999 12:00:00 AM | 9/14/2007 4:38 PM |
| Details | State | Insert | | | Active | 9/14/2007 4:38 PM |
| Dates | Registration Date | Insert | | | 10/1/1999 12:00:00 AM | 9/14/2007 4:38 PM |
| Dates | Signed By Date | Insert | | | | 9/14/2007 4:38 PM |
| Dates | Start Date | Insert | | | 10/1/1999 12:00:00 AM | 9/14/2007 4:38 PM |
| Terminations | Termination Comments | Insert | | | | 9/14/2007 4:38 PM |
| Terminations | Termination Date | Insert | | | | 9/14/2007 4:38 PM |
| Terminations | Termination Effective Date | Insert | | | | 9/14/2007 4:38 PM |
| Terminations | Termination Reason | Insert | | | | 9/14/2007 4:38 PM |
| Details | Comments Public | Insert | | | 9/14/07 - UPDATED ADDRESS (WAS P.O. BOX 249, CHOATE ROAD), CHOATE RD RENAMED POW WOW TRAIL | 9/14/2007 4:38 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | True | 10/1/1999 12:00 AM |
| Medicaid Billing | Medicaid: Number | Insert | | | 3140293 | 10/1/1999 12:00 AM |
| Medicaid Billing | Medicaid: State | Insert | | | MI | 10/1/1999 12:00 AM |