| Contacts | Primary Contact | Update | Group Change Request | Armistead, Racheal
Director of Pharmacy
Shawnee Christian Healthcare Center, Inc.
5027780001 | Burke, Stephanie
Pharmacist
Shawnee Christian Healthcare Center
5027780001 | 4/23/2025 11:14 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 3/28/2025 9:22 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 7100730110 | 3/28/2025 9:22 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | KY | 3/28/2025 9:22 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1003407719 | 3/28/2025 9:22 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | KY | 3/28/2025 9:22 AM |
| Details | Last Recertification Date | Update | Recertification | 2/5/2024 10:32:23 AM | 2/20/2025 9:30:00 AM | 2/20/2025 9:30 AM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2023 1:12:01 PM | 2/5/2024 10:32:23 AM | 2/5/2024 10:32 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Nelson, Lindsay
Interim CEO/COO
Shawnee Christian Healthcare Center
5027780001-1402 | Matzek, Kirstie
CEO
Shawnee Christian Healthcare Center
5027780001 | 5/4/2023 2:21 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 2/10/2023 9:49 AM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 7100191560 | 2/10/2023 9:49 AM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | KY | 2/10/2023 9:49 AM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1225333743 | 2/10/2023 9:49 AM |
| Medicaid Billing | NPI: State | Insert | Change Request | | KY | 2/10/2023 9:49 AM |
| Details | Last Recertification Date | Update | Recertification | 2/11/2022 6:51:45 PM | 1/30/2023 1:12:01 PM | 1/30/2023 1:12 PM |
| Contacts | Authorizing Official | Update | Change Request | Wardlaw, Ernest J
CEO
Shawnee Christian Healthcare
5026321710 | Nelson, Lindsay
Interim CEO/COO
Shawnee Christian Healthcare Center
5027780001-1402 | 1/27/2023 11:52 AM |
| Contacts | Primary Contact | Update | Group Change Request | Huhnerkoch, Daniel J
Finance Coordinator
Shawnee Christian Healthcare
5027780001-1403 | Armistead, Racheal
Director of Pharmacy
Shawnee Christian Healthcare Center, Inc.
5027780001 | 5/13/2022 7:04 AM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2021 12:12:49 PM | 2/11/2022 6:51:45 PM | 2/11/2022 6:51 PM |
| Details | Last Recertification Date | Update | Recertification | | 2/3/2021 12:12:49 PM | 2/3/2021 12:12 PM |
| Contacts | Primary Contact | Update | Change Request | Nelson, Lindsay
Director of Development and Grant Programs
Shawnee Christian Healthcare Center
5027780001 | Huhnerkoch, Daniel J
Finance Coordinator
Shawnee Christian Healthcare
5027780001-1403 | 10/28/2020 8:20 AM |
| Contacts | Authorizing Official | Update | Change Request | Maguire, Susan
CFO
Shawnee Christian Healthcare Center, Inc
5027780001 | Wardlaw, Ernest J
CEO
Shawnee Christian Healthcare
5026321710 | 10/28/2020 8:20 AM |
| Details | State | Update | | Approved | Active | 4/1/2020 12:05 AM |
| Contacts | Signed By | Insert | New Registration | | Maguire, Susan
CFO
Shawnee Christian Healthcare Center, Inc
5027780001 | 3/2/2020 7:13 AM |
| Details | 340B ID | Update | New Registration | | CHC28961-10 | 3/2/2020 7:13 AM |
| Dates | Participating Approval Date | Update | New Registration | | 3/2/2020 7:13:47 AM | 3/2/2020 7:13 AM |
| Details | State | Update | New Registration | Pending | Approved | 3/2/2020 7:13 AM |
| Dates | Signed By Date | Update | New Registration | | 1/14/2020 9:47:07 AM | 3/2/2020 7:13 AM |
| Dates | Start Date | Update | New Registration | | 4/1/2020 12:00:00 AM | 3/2/2020 7:13 AM |
| Addresses | Main Address | Insert | New Registration | |
2328 Cedar St
Louisville, KY 40212-1625 | 1/13/2020 4:27 PM |
| Addresses | Billing Address | Insert | New Registration | | Shawnee Christian Healthcare Center
234 Amy Ave
Louisville, KY 40212 | 1/13/2020 4:27 PM |
| Addresses | Shipping Address | Insert | New Registration | | Shawnee Christian Healthcare Center
234 Amy Ave
Louisville, KY 40212 | 1/13/2020 4:27 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Maguire, Susan
CFO
Shawnee Christian Healthcare Center, Inc
5027780001 | 1/13/2020 4:27 PM |
| Contacts | Primary Contact | Insert | New Registration | | Nelson, Lindsay
Director of Development and Grant Programs
Shawnee Christian Healthcare Center
5027780001 | 1/13/2020 4:27 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Details | Grant Number | Insert | New Registration | | H80CS28961 | 1/13/2020 4:27 PM |
| Details | 340B ID | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Details | Medicare Provider Number | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Details | Entity Name | Insert | New Registration | | Shawnee Christian Healthcare Center, Inc. | 1/13/2020 4:27 PM |
| Details | Program Code | Insert | New Registration | | CH | 1/13/2020 4:27 PM |
| Details | Entity Subname | Insert | New Registration | | The Wellness Center @ Byck Elementary | 1/13/2020 4:27 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Details | State | Insert | New Registration | | Pending | 1/13/2020 4:27 PM |
| Dates | Registration Date | Insert | New Registration | | 1/13/2020 4:27:21 PM | 1/13/2020 4:27 PM |
| Dates | Signed By Date | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Dates | Start Date | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Terminations | Termination Date | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 1/13/2020 4:27 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 1/13/2020 4:27 PM |