Covered Entity Details

RRC390195-00 LANKENAU MEDICAL CENTER (Terminated) - information as of 6/8/2025 11:56:11 PM

Main Details

Name

LANKENAU MEDICAL CENTER

Subdivision Name

Type

Rural Referral Center

Rural

340B ID

RRC390195-00

Medicare Provider Number

390195

Additional Details

Current Program Status

Terminated

Registration Date

10/9/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/24/2019

Last Recertification Date

8/31/2022

Termination Date
Termination Reason

4/1/2023
Change of covered entity type

Contacts

Authorizing Official

Lankenau Medical Center
Yonathan M Kebede, Vice President, Operations
(614) 323-9829

Primary Contact

Lankenau Medical Center
David K Showalter, System Director, Pharmacy Services
(484) 227-3611

Addresses

Street Address

100 LANCASTER AVE.
WYNNEWOOD, PA 19096

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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
PA	1007354280039	1245335629

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	HAPPY HARRY'S INC.	DBA: WALGREENS	10 EAST STREET ROAD	WEST CHESTER	PA	19382	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	HAPPY HARRY'S INC.	DBA: WALGREENS	51 BALTIMORE PIKE	GLEN MILLS	PA	19342	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1764	5627-99 CHESTNUT STREET	PHILADELPHIA	PA	19139	07/14/2022	10/01/2022	04/01/2023	04/01/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3681	5440 LANSDOWNE AVENUE	PHILADELPHIA	PA	19131	07/14/2022	10/01/2022	04/01/2023	04/01/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #3523	1105-09 N. 63RD STREET	PHILADELPHIA	PA	19151	07/14/2022	10/01/2022	04/01/2023	04/01/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #4611	5040 CITY LINE AVENUE	PHILADELPHIA	PA	19131	07/14/2022	10/01/2022	04/01/2023	04/01/2023
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #1320	640 MONTGOMERY AVENUE	NARBERTH	PA	19072	07/14/2022	10/01/2022	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO INC	DBA: WALGREENS # 04115	4201 N BROAD ST	PHILADELPHIA	PA	19140	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO. INC.	DBA:WALGREENS #15336	1 SOUTH BROAD STREET	PHILADELPHIA	PA	19107	07/16/2020	10/01/2020	05/23/2022	05/29/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07740	52 CHESTER PIKE	DARBY	PA	19023-2018	07/15/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #11595	245 N BROAD ST STE 1	PHILADELPHIA	PA	19107	07/15/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 06924	152 E LANCASTER AVENUE	PAOLI	PA	19301-1422	07/15/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	300 N. 63RD ST.	PHILADELPHIA	PA	19139	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04487	3620 CONCORD RD	ASTON	PA	19014	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 01106	1456 BETHLEHEM PIKE	FLOURTOWN	PA	19031	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07224	119 E DEKALB PIKE	KING OF PRUSSIA	PA	19406	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04429	150 N MACDADE BLVD.	GLENOLDEN	PA	19036	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #16519	1334 BAINBRIDGE ST	PHILADELPHIA	PA	19147	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07366	3300 DEKALB PIKE	EAST NORRITON	PA	19401	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	300 N. BRADFORD AVE.	WEST CHESTER	PA	19380	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 06837	699 W GERMANTOWN PIKE	EAST NORRITON	PA	19403-4233	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07014	2803 W RIDGE PIKE	NORRISTOWN	PA	19403-1534	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03663	4098 EDGEMONT AVE.	BROOKHAVEN	PA	19015	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #15554	2 W BALTIMORE AVE	LANSDOWNE	PA	19050	07/16/2020	10/01/2020	10/30/2020	10/30/2020
Contract Detail	WALGREEN EASTERN CO., INC.	100 E LANCASTER AVE STE 12		WYNNEWOOD	PA	19096-3400	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	190 WILMINGTON-WEST CHESTER PIKE	CHADDS FORD	PA	19317-9040	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 06331	2 BALTIMORE PIKE	SPRINGFIELD	PA	19064	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07336	1617 JOHN F KENNEDY BLVD LBBY W8	PHILADELPHIA	PA	19103	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 05523	901 OLD YORK RD	JENKINTOWN	PA	19046	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #15316	1227 LOCUST ST	PHILADELPHIA	PA	19107	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 07543	2310 W OREGON AVE	PHILADELPHIA	PA	19145-4122	07/16/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 06894	2727 W CHELTENHAM AVENUE	WYNCOTE	PA	19095	10/13/2020	01/01/2021	04/01/2023	04/01/2023
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS	494 NUTT RD.	PHOENIXVILLE	PA	19460-3354	10/13/2020	01/01/2021	04/01/2023	04/01/2023
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	07/15/2020	10/01/2020	04/01/2023	04/01/2023
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	07/15/2020	10/01/2020	04/01/2023	04/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
RRC390195-01	Child	RRC	LANKENAU MEDICAL CENTER	Main Line Health Center- Broomall - Radiology	1991 Sproul Road	Broomall	PA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2023 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2023 12:00:00 AM	2/2/2023 2:21 PM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	2/2/2023 2:21 PM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2023 12:00:00 AM	2/2/2023 2:21 PM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2023 12:00:00 AM	2/2/2023 2:21 PM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	2/2/2023 2:21 PM
Details	Last Recertification Date	Update	Recertification	8/18/2021 5:12:23 PM	8/31/2022 4:05:29 PM	8/31/2022 4:05 PM
Contacts	Authorizing Official	Update	AO Change Request	Robinson, Phil D President Lankenau Medical Center 4844762027	Kebede, Yonathan M Vice President, Operations Lankenau Medical Center 6143239829	7/29/2022 12:43 PM
Details	Last Recertification Date	Update	Recertification	8/18/2020 1:29:42 PM	8/18/2021 5:12:23 PM	8/18/2021 5:12 PM
Addresses	Main Address	Update	Recertification	100 LANCASTER AVE. WYNEWOOD, PA 19096	100 LANCASTER AVE. WYNNEWOOD, PA 19096	8/18/2020 1:29 PM
Medicaid Billing	NPI: State	Update	Recertification		PA	8/18/2020 1:29 PM
Details	Last Recertification Date	Update	Recertification		8/18/2020 1:29:42 PM	8/18/2020 1:29 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Contacts	Signed By	Insert	New Registration		Robinson, Phil D President Lankenau Medical Center 4844762027	10/24/2019 2:26 PM
Details	340B ID	Update	New Registration		RRC390195-00	10/24/2019 2:26 PM
Dates	Participating Approval Date	Update	New Registration		10/24/2019 2:26:40 PM	10/24/2019 2:26 PM
Details	State	Update	New Registration	Pending	Approved	10/24/2019 2:26 PM
Dates	Signed By Date	Update	New Registration		10/23/2019 12:40:55 PM	10/24/2019 2:26 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/24/2019 2:26 PM
Addresses	Main Address	Insert	New Registration		100 LANCASTER AVE. WYNEWOOD, PA 19096	10/9/2019 8:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/9/2019 8:53 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007354280039	10/9/2019 8:53 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	10/9/2019 8:53 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1245335629	10/9/2019 8:53 AM
Contacts	Primary Contact	Insert	New Registration		Showalter, David K System Director, Pharmacy Services Lankenau Medical Center 4842273611	10/9/2019 8:53 AM
Contacts	Authorizing Official	Insert	New Registration		Robinson, Phil D President Lankenau Medical Center 4844762027	10/9/2019 8:53 AM
Details	Last Recertification Date	Insert	New Registration			10/9/2019 8:53 AM
Details	Grant Number	Insert	New Registration			10/9/2019 8:53 AM
Details	340B ID	Insert	New Registration			10/9/2019 8:53 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/9/2019 8:53 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/9/2019 8:53 AM
Details	Medicare Provider Number	Insert	New Registration		390195	10/9/2019 8:53 AM
Details	Entity Name	Insert	New Registration		LANKENAU MEDICAL CENTER	10/9/2019 8:53 AM
Details	Program Code	Insert	New Registration		RRC	10/9/2019 8:53 AM
Details	Entity Subname	Insert	New Registration			10/9/2019 8:53 AM
Dates	Participating Approval Date	Insert	New Registration			10/9/2019 8:53 AM
Details	State	Insert	New Registration		Pending	10/9/2019 8:53 AM
Dates	Registration Date	Insert	New Registration		10/9/2019 8:53:32 AM	10/9/2019 8:53 AM
Dates	Signed By Date	Insert	New Registration			10/9/2019 8:53 AM
Dates	Start Date	Insert	New Registration			10/9/2019 8:53 AM
Terminations	Termination Comments	Insert	New Registration			10/9/2019 8:53 AM
Terminations	Termination Date	Insert	New Registration			10/9/2019 8:53 AM
Terminations	Termination Effective Date	Insert	New Registration			10/9/2019 8:53 AM
Terminations	Termination Reason	Insert	New Registration			10/9/2019 8:53 AM