Covered Entity Details

DSH230066CG MERCY HEALTH HACKLEY CAMPUS (Terminated) - information as of 4/25/2025 8:33:21 PM

Main Details

Name

MERCY HEALTH HACKLEY CAMPUS

Subdivision Name

Mercy Health Emergency - Hackley Campus - Emergency Services

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH230066CG

Medicare Provider Number

230066

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/14/2020

Participating Start Date

10/1/2020

Participating Approval Date

7/17/2020

Last Recertification Date

Termination Date
Termination Reason

7/1/2021
Site closure

Contacts

Authorizing Official

Mercy Health
Kristi Nagengast, Vice President of Finance
(231) 672-3802

Primary Contact

Mercy Health Muskegon
Scott Butler, 340B Program Coordinator
(231) 672-4229

Addresses

Street Address

1700 Clinton St.
Muskegon, MI 49442

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?
No

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
DSH230066A	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	Mercy Health General Campus Medi-Center	1700 Oak Ave.	Muskegon	MI	Terminated
DSH230066AA	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	LAKES FAMILY MEDICINE	6207 HARVEY ST	NORTON SHORES	MI	Terminated
DSH230066AB	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Sherman Pavilion	1150 E SHERMAN BLVD	MUSKEGON	MI	Terminated
DSH230066AC	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Academic Geriatrics - Sherman Pavilion	1150 E SHERMAN BLVD	MUSKEGON	MI	Active
DSH230066AD	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	MERCY ANTICOAGULATION	1212 E SHERMAN BLVD	MUSKEGON	MI	Terminated
DSH230066AE	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Neurosurgery - Sherman Pavilion	1150 E. Sherman Blvd.	MUSKEGON	MI	Active
DSH230066AF	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Cardiology - Muskegon	1223 Mercy Dr.	MUSKEGON	MI	Active
DSH230066AG	Child	DSH	Mercy Health Muskegon	ADULT MEDICINE SPECIALIST	6401 PRAIRIE ST	NORTON SHORES	MI	Terminated
DSH230066AH	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Heart Center, Cardiology - Muskegon	1212 E SHERMAN BLVD	MUSKEGON	MI	Active
DSH230066AJ	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	NORTHSHORE FAMILY MEDICINE	1915 HOLTON RD	MUSKEGON	MI	Terminated
DSH230066AK	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care & Pediatrics - North Muskegon	2006 Holton Road	NORTH MUSKEGON	MI	Active
DSH230066AL	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Norton Shores - Suite 220	3570 Henry Street	Norton Shores	MI	Active
DSH230066AM	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Lakes Village	6401 PRAIRIE ST	NORTON SHORES	MI	Active
DSH230066AN	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Spring Lake	601 W SAVIDGE ST	SPRING LAKE	MI	Active
DSH230066AP	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	HARBOUR POINTE MEDICAL ASSOCIATES	3587 HENRY ST	MUSKEGON	MI	Terminated
DSH230066AQ	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	HARBOUR VIEW FAMILY MEDICINE	1909 RUDDIMAN DR	MUSKEGON	MI	Terminated
DSH230066AR	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Norton Shores - Suite 120	3570 Henry Street	Norton Shores	MI	Active
DSH230066AS	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	HARBORWOOD AT THE LAKES	6401 PRAIRIE ST	NORTON SHORES	MI	Terminated
DSH230066AT	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Academic Family Medicine - Fruitport	3443 FARR RD	FRUITPORT	MI	Active
DSH230066AU	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	BEAR CREEK HEALTH CENTER	1877 N GETTY ST	MUSKEGON	MI	Terminated
DSH230066AV	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Muskegon Campus	1223 MERCY DR	MUSKEGON	MI	Terminated
DSH230066AW	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Wound Care - Muskegon Campus	1560 E SHERMAN BLVD	MUSKEGON	MI	Active
DSH230066AX	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Gastroenterology - Muskegon	1675 LEAHY ST	MUSKEGON	MI	Active
DSH230066AY	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Breast Center - Lakes Village	6401 Prairie St. Ste. 2300	NORTON SHORES	MI	Active
DSH230066AZ	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Sleep Medicine - Muskegon Campus	1277 Mercy Drive	Muskegon	MI	Active
DSH230066B	Child	DSH	Mercy Health Muskegon	Mercy Health Lakes Urgent Care	6401 Prairie Dr.	NORTON SHORES	MI	Terminated
DSH230066BA	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Academic Internal Medicine -Sherman Pavilion	1150 E. Sherman Blvd., Ste. 1100	Muskegon	MI	Active
DSH230066BB	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Neuropsychology - Muskegon Campus	1277 Mercy Drive	Muskegon	MI	Active
DSH230066BC	Child	DSH	Trinity Health Muskegon Hospital	MH - Mercy Campus / Hyperbaric Service	1560 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066BD	Child	DSH	Trinity Health Muskegon Hospital	Mercy Health Rehabilitation - Lakes Village / Physical Therapy	6401 Prairie St. Ste. 1800	Norton Shores	MI	Terminated
DSH230066BE	Child	DSH	Trinity Health Muskegon Hospital	Mercy Health Norton Shores - Norton Rehabilitation - Suite 200	3570 Henry Street	Muskegon	MI	Terminated
DSH230066BF	Child	DSH	Trinity Health Muskegon Hospital	Mercy Health Rehabilitation - Lakeshore Medical Whitehall / Rehab Therapy	905 E. Colby St. Ste. 140	Whitehall	MI	Terminated
DSH230066BG	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	MH - Mercy Campus / Cardiac Catheterization - Special Procedures	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066BH	Child	DSH	Trinity Health Muskegon Hospital	MH - Mercy Campus / Mercy Rehab Center	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066BJ	Child	DSH	Mercy Health Muskegon	MH - Mercy Campus / Cardiac Catheterization - PET Scan	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066BK	Child	DSH	Mercy Health Muskegon	MH - Mercy Campus / Operating Room - Perfusion	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066BL	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, McClees Clinic - Hackley	1675 Leahy St.	Muskegon	MI	Active
DSH230066BM	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	Mercy Health Hackley Campus / Infectious Disease - 96200	1700 Clinton St.	Muskegon	MI	Terminated
DSH230066BN	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Hepatitis C Clinic - Hackley	1675 Leahy St.	Muskegon	MI	Active
DSH230066BP	Child	DSH	Mercy Health Muskegon	Mercy Health Hackley Campus / Ambulatory Care - 88734	1700 Clinton St.	Muskegon	MI	Terminated
DSH230066BQ	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	WEST MICHIGAN INTERNAL MEDICINE - Internal Medicine	957 BROOKHAVEN CT	MUSKEGON	MI	Terminated
DSH230066BR	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Obstetrics & Gynecology - Lakes Village	6401 Prairie St.	Norton Shores	MI	Active
DSH230066BS	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Academic Obstetrics and Gynecology - Hackley	1675 Leahy St.	Muskegon	MI	Active
DSH230066BT	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Obstetrics & Gynecology - Hackley	1675 Leahy St.	Muskegon	MI	Active
DSH230066BU	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Obstetrics & Gynecology - Grand Haven	1445 Sheldon Rd.	Grand Haven	MI	Active
DSH230066BV	Child	DSH	Mercy Health Muskegon	North Muskegon Urgent Care - Emergency Medicine	2006 Holton Rd	Muskegon	MI	Terminated
DSH230066BW	Child	DSH	Mercy Health Muskegon	Sherman Urgent Care - Emergency Medicine	1670 E Sherman Blvd.	Muskegon	MI	Terminated
DSH230066BX	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	Mercy Health Hackley Campus Pain Clinic - Pain Medicine	1700 Clinton St.	Muskegon	MI	Terminated
DSH230066BY	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Gastroenterology - Grand Haven	1310 Wisconsin St.	Grand Haven	MI	Active
DSH230066BZ	Child	DSH	Mercy Health Muskegon	Ambulatory Pharmacy Services - Anticoagulation Services	1212 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066C	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd.	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066CA	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Pulmonology - Grand Haven	1310 Wisconsin St.	Grand Haven	MI	Active
DSH230066CB	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - West Olive	15151 Stanton St	West Olive	MI	Active
DSH230066CC	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Quarterline	221 S Quarterline Rd.	Muskegon	MI	Terminated
DSH230066CD	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Grand Haven - Suite 100	1310 Wisconsin St	Grand Haven	MI	Active
DSH230066CE	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Grand Haven - Suite 103	1310 Wisconsin St,	Grand Haven	MI	Active
DSH230066CF	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Primary Care - Grand Haven - Suite 301	1310 Wisconsin St.	Grand Haven	MI	Active
DSH230066CG	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	Mercy Health Emergency - Hackley Campus - Emergency Services	1700 Clinton St.	Muskegon	MI	Terminated
DSH230066CH	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Diabetes and Endocrinology - Hackley - Diabetes and Endocrinology	1675 Leahy St.	Muskegon	MI	Active
DSH230066CJ	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Osteopathic Manipulative Medicine - Sherman Pavilion - Osteopathic Medicine	1150 E. Sherman Blvd.	Muskegon	MI	Active
DSH230066CK	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Neurology - Grand Haven - Neurology	1310 Wisconsin St.	Grand Haven	MI	Active
DSH230066CL	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Urogynecology - Lakes Village - Urogynecology	6401 Prairie St.	Norton Shores	MI	Active
DSH230066CM	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Pulmonology - Muskegon Campus - Pulmonary Medicine	1560 E. Sherman Blvd.	Muskegon	MI	Active
DSH230066CN	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Aesthetics - Norton Shores - Aesthetics	3570 Henry St.	Norton Shores	MI	Active
DSH230066CP	Child	DSH	Trinity Health Muskegon Hospital	THMG RECOVERY MEDICINE-NORTON SHORE - Substance Use Recovery Services	3570 HENRY ST	NORTON SHORES	MI	Active
DSH230066CQ	Child	DSH	Trinity Health Muskegon Hospital	THMG INFECTIOUS DISEASE - HACKLEY - Infectious Disease	1675 LEAHY ST	MUSKEGON	MI	Active
DSH230066CR	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Neurology - Sherman Pavillion - Neurology	1150 E. Sherman Blvd.	Muskegon	MI	Approved
DSH230066CS	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Physical Medicine and Spine – Sherman Pavilion - Physical Medicine and Spine	1150 E. Sherman Blvd.	Muskegon	MI	Approved
DSH230066CT	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Medical Group, Sleep Medicine - Grand Haven - Sleep Medicine	1310 Wisconsin St.	Grand Haven	MI	Approved
DSH230066CU	Child	DSH	Trinity Health Muskegon Hospital	Trinity Health Heart Center - Pharmacotherapy - Muskegon - Pharmacotherapy	1212 E. Sherman Blvd.	Muskegon	MI	Approved
DSH230066D	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Endoscopy	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066E	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Recovery Room	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066F	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Anesthesiology	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066G	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Emergency Department	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066H	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Electrocardiology - Vascular Lab	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066J	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Radiology - Diagnostics	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066K	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Radiology Diagnostics - Ultrasound	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066L	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Radiology - Diagnostic - Dexascan	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066M	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Radioisotope - Nuclear Medicine	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066N	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / CT Scan	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066P	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / MRI	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066Q	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / MRI - Mobile MRI	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066R	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Cardia Catheterization - Cardiac Cath Lab	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066S	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Laboratory - Clinical Lab	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066T	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Respiratory Therapy - Respiratory Care	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066U	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Physical Therapy - House Rehab Services	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066V	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Electrocardiology - Physiology	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066W	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Electrocardiology - Echocardiology	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066X	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Cardiac Catheterization - Heart and Vascular Prep	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066Y	Child	DSH	Mercy Health Muskegon	Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Laboratory - Laboratory Chemistry	1500 E. Sherman Blvd.	Muskegon	MI	Terminated
DSH230066Z	Child	DSH	MERCY HEALTH HACKLEY CAMPUS	NORRIS CREEK	14 N 3RD AVE	FRUITPORT	MI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Nagengast, Kristi Vice President of Finance Mercy Health 2317281950	Nagengast, Kristi Vice President of Finance Mercy Health 2316723802	8/18/2021 6:45 AM
Contacts	Signed By	Update	Profile Change Request	Nagengast, Kristi Vice President of Finance Mercy Health 2317281950	Nagengast, Kristi Vice President of Finance Mercy Health 2316723802	8/18/2021 6:45 AM
Contacts	Primary Contact	Update	Profile Change Request	Butler, Scott 340B Program Coordinator Mercy Health Hackley Campus 2316724229	Butler, Scott 340B Program Coordinator Mercy Health Muskegon 2316724229	7/16/2021 9:20 AM
Details	State	Update		To Be Terminated	Terminated	7/1/2021 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		8/3/2020 12:00:00 AM	6/27/2021 9:18 AM
Details	State	Update	Termination Request	Active	To Be Terminated	6/27/2021 9:18 AM
Terminations	Termination Comments	Update	Termination Request		All ER Services for Mercy Health Hackley Campus (DSH230066) Emergency Dept. - DSH230066CG (1700 Clinton St.) were methodically over-time transitioned to the HRSA registered childsite "Mercy Health Muskegon Pharmacy - 1500 East Sherman Blvd. / Emergency Department - DSH230066G" as a migration of professional Emergency Services to the 1500 E. Sherman Childsite Hospital ER department.	6/27/2021 9:18 AM
Terminations	Termination Date	Update	Termination Request		7/1/2021 12:00:00 AM	6/27/2021 9:18 AM
Terminations	Termination Effective Date	Update	Termination Request		10/18/2020 12:00:00 AM	6/27/2021 9:18 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	6/27/2021 9:18 AM
Details	State	Update		Approved	Active	10/1/2020 12:01 AM
Contacts	Signed By	Insert	New Registration		Nagengast, Kristi Vice President of Finance Mercy Health 2317281950	7/17/2020 1:33 PM
Details	340B ID	Update	New Registration		DSH230066CG	7/17/2020 1:33 PM
Details	Entity Name	Update	New Registration	MERCY HEALTH MUSKEGON	MERCY HEALTH HACKLEY CAMPUS	7/17/2020 1:33 PM
Details	Entity Subname	Update	New Registration	Mercy Health Emergency - Hackley Campus	Mercy Health Emergency - Hackley Campus - Emergency Services	7/17/2020 1:33 PM
Dates	Participating Approval Date	Update	New Registration		7/17/2020 1:33:59 PM	7/17/2020 1:33 PM
Details	State	Update	New Registration	Pending	Approved	7/17/2020 1:33 PM
Dates	Signed By Date	Update	New Registration		7/14/2020 7:52:15 PM	7/17/2020 1:33 PM
Dates	Start Date	Update	New Registration		10/1/2020 12:00:00 AM	7/17/2020 1:33 PM
Addresses	Main Address	Insert	New Registration		1700 Clinton St. Muskegon, MI 49442	7/14/2020 11:07 AM
Contacts	Authorizing Official	Insert	New Registration		Nagengast, Kristi Vice President of Finance Mercy Health 2317281950	7/14/2020 11:07 AM
Contacts	Primary Contact	Insert	New Registration		Butler, Scott 340B Program Coordinator Mercy Health Hackley Campus 2316724229	7/14/2020 11:07 AM
Details	Last Recertification Date	Insert	New Registration			7/14/2020 11:07 AM
Details	Grant Number	Insert	New Registration			7/14/2020 11:07 AM
Details	340B ID	Insert	New Registration			7/14/2020 11:07 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/14/2020 11:07 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/14/2020 11:07 AM
Details	Medicare Provider Number	Insert	New Registration		230066	7/14/2020 11:07 AM
Details	Entity Name	Insert	New Registration		MERCY HEALTH MUSKEGON	7/14/2020 11:07 AM
Details	Program Code	Insert	New Registration		DSH	7/14/2020 11:07 AM
Details	Entity Subname	Insert	New Registration		Mercy Health Emergency - Hackley Campus	7/14/2020 11:07 AM
Dates	Participating Approval Date	Insert	New Registration			7/14/2020 11:07 AM
Details	State	Insert	New Registration		Pending	7/14/2020 11:07 AM
Dates	Registration Date	Insert	New Registration		7/14/2020 11:07:45 AM	7/14/2020 11:07 AM
Dates	Signed By Date	Insert	New Registration			7/14/2020 11:07 AM
Dates	Start Date	Insert	New Registration			7/14/2020 11:07 AM
Terminations	Termination Comments	Insert	New Registration			7/14/2020 11:07 AM
Terminations	Termination Date	Insert	New Registration			7/14/2020 11:07 AM
Terminations	Termination Effective Date	Insert	New Registration			7/14/2020 11:07 AM
Terminations	Termination Reason	Insert	New Registration			7/14/2020 11:07 AM