Covered Entity Details

SCH230058-12 MUNSON HEALTHCARE GRAYLING HOSPITAL (Active) - information as of 6/25/2025 12:55:46 AM

Main Details

Name

MUNSON HEALTHCARE GRAYLING HOSPITAL

Subdivision Name

Milltown Primary Care - Primary Care

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH230058-12

Medicare Provider Number

230058

Outpatient Facility Provider Number

238717

Additional Details

Current Program Status

Active

Registration Date

1/15/2024

Participating Start Date

4/1/2024

Participating Approval Date

2/6/2024

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Munson Healthcare
Kathleen M LaRaia, Vice President
(231) 392-8410

Primary Contact

Munson Healthcare
Sam Patrick Niemi, System Director Reimbursement
(231) 935-7761

Addresses

Street Address

1200 W North Down River Rd
Grayling, MI 49738

Billing Address

Munson Healthcare Grayling Hospital
PO Box 669
Traverse City, MI 49685

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating Start Date 7/1/2021, Termination date 4/1/2022, Reinstatement 4/1/2024	02/05/2024

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
MI	1083010953	1083010953

Shipping Addresses

Shipping Address 1

Munson Healthcare Grayling Hospital
1100 E Michigan Ave
Grayling, MI 49738

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
SCH230058-01	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Roscommon Community Health Center	234 Lake Street	Roscommon	MI	Active
SCH230058-02	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Grayling Community Health Center	1250 E. Michigan Avenue	Grayling	MI	Active
SCH230058-03	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Prudenville Community Health Center	2585 W. Houghton Lake Drive	Prudenville	MI	Active
SCH230058-04	Child	SCH	MERCY NORTH - GRAYLING	MUNSON HEALTHCARE GRAYLING / Urology	809 MICHIGAN AVE	GRAYLING	MI	Terminated
SCH230058-05	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Prudenville Community Health Center - Orthopedics	2585 W. Houghton Lake Drive	Prudenville	MI	Active
SCH230058-06	Child	SCH	Munson Healthcare Grayling Hospital	Grayling Community Health Center - Elder Care	1250 E. Michigan Avenue	Grayling	MI	Terminated
SCH230058-07	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Grayling Community Health Center - Psychiatric Services	1250 E. Michigan Avenue	Grayling	MI	Active
SCH230058-08	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Grayling Community Health Center - Obstetrics	1250 E. Michigan Avenue	Grayling	MI	Active
SCH230058-09	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Grayling Community Health Center - Pediatrics	1250 E. Michigan Avenue	Grayling	MI	Active
SCH230058-10	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Grayling Community Health Center - Walk In Clinic	1250 E. Michigan Avenue	Grayling	MI	Active
SCH230058-11	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Prudenville Community Health Center - Walk-In Clinic	2585 W. Houghton Lake Drive	Prudenville	MI	Active
SCH230058-12	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Milltown Primary Care - Primary Care	1200 W North Down River Rd	Grayling	MI	Active
SCH230058-13	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Prudenville Community Health Center - OB/GYN	2585 W. Houghton Lake Drive	Prudenville	MI	Active
SCH230058-14	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	Traverse Heart & Vascular - Grayling - Heart and Vascular	1107 East Michigan Avenue	Grayling	MI	Active
SCH230058-15	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	MUNSON HEALTHCARE GRAYLING - Mio Primary Care - Primary Care	1321 S MOUNT TOM RD	MIO	MI	Active
SCH230058-16	Child	SCH	MUNSON HEALTHCARE GRAYLING HOSPITAL	MUNSON HEALTHCARE GRAYLING - MIO - OB/GYN - Obstetrics and Gynecology	1321 S MOUNT TOM RD	MIO	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/20/2024 9:20:37 AM	8/20/2024 9:20 AM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Addresses	Billing Address	Insert	Reinstatement		Munson Healthcare Grayling Hospital PO Box 669 Traverse City, MI 49685	2/6/2024 9:33 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	2/6/2024 9:33 AM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1083010953	2/6/2024 9:33 AM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		MI	2/6/2024 9:33 AM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1083010953	2/6/2024 9:33 AM
Medicaid Billing	NPI: State	Insert	Reinstatement		MI	2/6/2024 9:33 AM
Contacts	Authorizing Official	Update	Reinstatement	Maitland, Alicia CFO Munson Healthcare 2319357840	LaRaia, Kathleen M Vice President Munson Healthcare 2313928410	2/6/2024 9:33 AM
Contacts	Signed By	Update	Reinstatement	Hepler, Mark CFO Munson Healthcare 2319356702	LaRaia, Kathleen M Vice President Munson Healthcare 2313928410	2/6/2024 9:33 AM
Details	Last Recertification Date	Update	Reinstatement	8/19/2021 10:31:44 AM		2/6/2024 9:33 AM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	4/1/2022 12:00:00 AM		2/6/2024 9:33 AM
Details	Entity Name	Update	Reinstatement	Munson Healthcare Grayling Hospital	MUNSON HEALTHCARE GRAYLING HOSPITAL	2/6/2024 9:33 AM
Dates	Participating Approval Date	Update	Reinstatement	4/18/2021 2:51:10 PM	2/6/2024 9:33:29 AM	2/6/2024 9:33 AM
Details	State	Update	Reinstatement	Terminated	Approved	2/6/2024 9:33 AM
Dates	Registration Date	Update	Reinstatement	4/12/2021 5:58:19 PM	1/15/2024 3:43:40 PM	2/6/2024 9:33 AM
Dates	Signed By Date	Update	Reinstatement	4/13/2021 3:24:14 PM	1/16/2024 9:27:58 AM	2/6/2024 9:33 AM
Dates	Start Date	Update	Reinstatement	7/1/2021 12:00:00 AM	4/1/2024 12:00:00 AM	2/6/2024 9:33 AM
Terminations	Termination Date	Update	Reinstatement	4/1/2022 12:00:00 AM		2/6/2024 9:33 AM
Terminations	Termination Effective Date	Update	Reinstatement	4/1/2022 12:00:00 AM		2/6/2024 9:33 AM
Terminations	Termination Reason	Update	Reinstatement	Change of covered entity type		2/6/2024 9:33 AM
Details	Comments Public	Insert	Reinstatement		Participating Start Date 7/1/2021, Termination date 4/1/2022, Reinstatement 4/1/2024	2/5/2024 12:33 PM
Contacts	Primary Contact	Update	Profile Change Request	Niemi, Sam Patrick Manager Reimbursement Munson Healthcare 2319357761	Niemi, Sam Patrick System Director Reimbursement Munson Healthcare 2319357761	5/2/2022 12:31 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	2/22/2022 8:18 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	2/22/2022 8:18 AM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	2/22/2022 8:18 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	2/22/2022 8:18 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	2/22/2022 8:18 AM
Addresses	Shipping Address	Insert	Change Request		Munson Healthcare Grayling Hospital 1100 E Michigan Ave Grayling, MI 49738	1/4/2022 10:50 AM
Details	Last Recertification Date	Update	Recertification		8/19/2021 10:31:44 AM	8/19/2021 10:31 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Authorizing Official	Update	AO Change Request	Hepler, Mark CFO Munson Healthcare 2319356702	Maitland, Alicia CFO Munson Healthcare 2319357840	6/23/2021 9:47 AM
Contacts	Signed By	Insert	New Registration		Hepler, Mark CFO Munson Healthcare 2319356702	4/18/2021 2:51 PM
Details	340B ID	Update	New Registration		SCH230058-12	4/18/2021 2:51 PM
Details	Entity Name	Update	New Registration	MUNSON HEALTHCARE GRAYLING HOSPITAL	Munson Healthcare Grayling Hospital	4/18/2021 2:51 PM
Details	Entity Subname	Update	New Registration	Milltown Primary Care	Milltown Primary Care - Primary Care	4/18/2021 2:51 PM
Dates	Participating Approval Date	Update	New Registration		4/18/2021 2:51:10 PM	4/18/2021 2:51 PM
Details	State	Update	New Registration	Pending	Approved	4/18/2021 2:51 PM
Dates	Signed By Date	Update	New Registration		4/13/2021 3:24:14 PM	4/18/2021 2:51 PM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	4/18/2021 2:51 PM
Addresses	Main Address	Insert	New Registration		1200 W North Down River Rd Grayling, MI 49738	4/12/2021 5:58 PM
Addresses	Billing Address	Insert	New Registration		Munson Healthcare Grayling Hospital PO Box 669 Traverse City, MI 49685	4/12/2021 5:58 PM
Contacts	Authorizing Official	Insert	New Registration		Hepler, Mark CFO Munson Healthcare 2319356702	4/12/2021 5:58 PM
Contacts	Primary Contact	Insert	New Registration		Niemi, Sam Patrick Manager Reimbursement Munson Healthcare 2319357761	4/12/2021 5:58 PM
Details	Assistance Received From Date	Insert	New Registration			4/12/2021 5:58 PM
Details	Assistance Received To Date	Insert	New Registration			4/12/2021 5:58 PM
Details	Last Recertification Date	Insert	New Registration			4/12/2021 5:58 PM
Details	Grant Number	Insert	New Registration			4/12/2021 5:58 PM
Details	340B ID	Insert	New Registration			4/12/2021 5:58 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/12/2021 5:58 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/12/2021 5:58 PM
Details	Medicare Provider Number	Insert	New Registration		230058	4/12/2021 5:58 PM
Details	Entity Name	Insert	New Registration		MUNSON HEALTHCARE GRAYLING HOSPITAL	4/12/2021 5:58 PM
Details	NOFO Number	Insert	New Registration			4/12/2021 5:58 PM
Details	Program Code	Insert	New Registration		SCH	4/12/2021 5:58 PM
Details	Entity Subname	Insert	New Registration		Milltown Primary Care	4/12/2021 5:58 PM
Dates	Participating Approval Date	Insert	New Registration			4/12/2021 5:58 PM
Details	State	Insert	New Registration		Pending	4/12/2021 5:58 PM
Dates	Registration Date	Insert	New Registration		4/12/2021 5:58:19 PM	4/12/2021 5:58 PM
Dates	Signed By Date	Insert	New Registration			4/12/2021 5:58 PM
Dates	Start Date	Insert	New Registration			4/12/2021 5:58 PM
Terminations	Termination Comments	Insert	New Registration			4/12/2021 5:58 PM
Terminations	Termination Date	Insert	New Registration			4/12/2021 5:58 PM
Terminations	Termination Effective Date	Insert	New Registration			4/12/2021 5:58 PM
Terminations	Termination Reason	Insert	New Registration			4/12/2021 5:58 PM