Covered Entity Details

CAH141313-02 MASON DISTRICT HOSPITAL (Active) - information as of 5/20/2025 12:45:56 AM

Main Details

Name

MASON DISTRICT HOSPITAL

Subdivision Name

Mason Hospital Home Health - Home Health

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH141313-02

Medicare Provider Number

141313

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/8/2020

Participating Start Date

7/1/2020

Participating Approval Date

4/21/2020

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Mason District Hospital
Leann Kay Bonnett, CFO
(309) 543-8505

Primary Contact

Mason District Hospital
Jeremiah Vance, Director of Pharmacy
(309) 543-8501

Addresses

Street Address

741 East Laurel Street
Havana, IL 62644

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
IL	376017857002	1265548010

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH141313-01	Child	CAH	MASON DISTRICT HOSPITAL	MASON HOSPITAL DISTRICT - Manito Medical Associates	1301 S EAST AVE	MANITO	IL	Active
CAH141313-02	Child	CAH	MASON DISTRICT HOSPITAL	Mason Hospital Home Health - Home Health	741 East Laurel Street	Havana	IL	Active
CAH141313-03	Child	CAH	MASON DISTRICT HOSPITAL	MASON HOSPITAL DISTRICT - Mason City Medical Associates	122 EAST ELM STREET	MASON CITY	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/14/2023 9:56:47 AM	8/12/2024 8:48:26 AM	8/12/2024 8:48 AM
Contacts	Primary Contact	Update	PC Change Request	Roch, Penny Pharmacy Director MasonDistrict Hospital 3095438501	Vance, Jeremiah Director of Pharmacy Mason District Hospital 3095438501	8/9/2024 12:29 PM
Details	Last Recertification Date	Update	Recertification	8/24/2022 7:50:31 AM	8/14/2023 9:56:47 AM	8/14/2023 9:56 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 8:18:49 AM	8/24/2022 7:50:31 AM	8/24/2022 7:50 AM
Addresses	Main Address	Update	Change Request	741 E Laurel Havana, IL 62644	741 East Laurel Street Havana, IL 62644	5/2/2022 8:54 AM
Details	Last Recertification Date	Update	Recertification	8/19/2020 11:14:24 AM	8/16/2021 8:18:49 AM	8/16/2021 8:18 AM
Medicaid Billing	NPI: State	Update	Recertification		IL	8/19/2020 11:14 AM
Details	Last Recertification Date	Update	Recertification		8/19/2020 11:14:24 AM	8/19/2020 11:14 AM
Details	State	Update		Approved	Active	7/1/2020 12:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/21/2020 7:21 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		376017857002	4/21/2020 7:21 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	4/21/2020 7:21 AM
Contacts	Signed By	Insert	New Registration		Bonnett, Leann Kay CFO Mason District Hospital 3095438505	4/21/2020 7:21 AM
Details	340B ID	Update	New Registration		CAH141313-02	4/21/2020 7:21 AM
Details	Entity Subname	Update	New Registration	Mason Hospital Home Health	Mason Hospital Home Health - Home Health	4/21/2020 7:21 AM
Dates	Participating Approval Date	Update	New Registration		4/21/2020 7:21:21 AM	4/21/2020 7:21 AM
Details	State	Update	New Registration	Pending	Approved	4/21/2020 7:21 AM
Dates	Signed By Date	Update	New Registration		4/9/2020 8:26:33 AM	4/21/2020 7:21 AM
Dates	Start Date	Update	New Registration		7/1/2020 12:00:00 AM	4/21/2020 7:21 AM
Addresses	Main Address	Insert	New Registration		741 E Laurel Havana, IL 62644	4/8/2020 5:22 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1265548010	4/8/2020 5:22 PM
Contacts	Primary Contact	Insert	New Registration		Roch, Penny Pharmacy Director MasonDistrict Hospital 3095438501	4/8/2020 5:22 PM
Contacts	Authorizing Official	Insert	New Registration		Bonnett, Leann Kay CFO Mason District Hospital 3095438505	4/8/2020 5:22 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2020 5:22 PM
Details	Grant Number	Insert	New Registration			4/8/2020 5:22 PM
Details	340B ID	Insert	New Registration			4/8/2020 5:22 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2020 5:22 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2020 5:22 PM
Details	Medicare Provider Number	Insert	New Registration		141313	4/8/2020 5:22 PM
Details	Entity Name	Insert	New Registration		MASON DISTRICT HOSPITAL	4/8/2020 5:22 PM
Details	Program Code	Insert	New Registration		CAH	4/8/2020 5:22 PM
Details	Entity Subname	Insert	New Registration		Mason Hospital Home Health	4/8/2020 5:22 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2020 5:22 PM
Details	State	Insert	New Registration		Pending	4/8/2020 5:22 PM
Dates	Registration Date	Insert	New Registration		4/8/2020 5:22:40 PM	4/8/2020 5:22 PM
Dates	Signed By Date	Insert	New Registration			4/8/2020 5:22 PM
Dates	Start Date	Insert	New Registration			4/8/2020 5:22 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2020 5:22 PM
Terminations	Termination Date	Insert	New Registration			4/8/2020 5:22 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2020 5:22 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2020 5:22 PM