340B Drug Pricing Program Database


RRC150018-00 ELKHART GENERAL HOSPITAL (Active) - information as of 5/23/2025 12:05:22 AM

Main Details
ELKHART GENERAL HOSPITAL
Rural Referral Center
No
RRC150018-00
150018


Additional Details
Active
7/14/2021
10/1/2021
7/30/2021
9/6/2024

Contacts

Beacon Health System, Inc.
JEFFREY P. COSTELLO, CFO
(574) 647-3549

Beacon Health System-Elkhart General Hospital
Holly Kaczmarek, Director of Pharmacy
(574) 523-3447

Addresses

600 EAST BLVD
ELKHART, IN 46514

Beacon Health System, Inc
615 N Michigan St
South Bend, IN 46601


  • Comments
  • Medicaid Billing
  • Shipping Addresses
  • Contract Pharmacies
  • Parent/Child
  • History
Comments
CommentLast Updated On 
No records to display.
Medicaid Billing

Yes
StateMedicaid NumberNPI Number
IN100268340A,100295480A1477551489,1134128705
MI 1477551489
IL 1477551489
Shipping Addresses

Same as Street Address
Contract Pharmacies
Contract DetailPharmacy NameAddressAddress Cont.CityStateZip CodeApproval DateBegin DateCarve-In Effective DateTermination DateLast Updated On
Contract DetailCVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870607/02/202410/01/2024  10/01/2024
Contract DetailCVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005607/02/202410/01/2024  10/01/2024
Contract DetailHOOK-SUPERX, L.L.C.DBA: CVS/PHARMACY # 06469 900 E. BRISTOL ST.
ELKHARTIN4651407/02/202410/01/2024  10/01/2024
Contract DetailHOOK-SUPERX, L.L.C.DBA: CVS/PHARMACY # 07188 102 E US HIGHWAY 20
MIDDLEBURYIN4654007/02/202410/01/2024  10/01/2024
Contract DetailHOOK-SUPERX, L.L.C.DBA: CVS/PHARMACY # 06475 104 W. HIVELY AVE.
ELKHARTIN4651707/02/202410/01/2024  10/01/2024
Contract DetailHOOK-SUPERX, L.L.C.DBA: CVS/PHARMACY # 06460 3600 CASSOPOLIS ST.
ELKHARTIN4651407/02/202410/01/2024  10/01/2024
Parent/Child
340B IDHierarchyEntity TypeNameSub NameAddressCityState340B Status
RRC150018-01ChildRRCELKHART GENERAL HOSPITALELKHART CARDIOLOGY - Diagnostic Cardiology ECHO303 S NAPPANEE STELKHARTINActive
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
ContactsAuthorizing OfficialUpdateProfile Change RequestCOSTELLO, JEFFREY P. CFO Memorial Hospital of South Bend 5746473549COSTELLO, JEFFREY P. CFO Beacon Health System, Inc. 57464735493/12/2025 9:08 AM
ContactsSigned ByUpdateProfile Change RequestCOSTELLO, JEFFREY P. CFO Memorial Hospital of South Bend 5746473549COSTELLO, JEFFREY P. CFO Beacon Health System, Inc. 57464735493/12/2025 9:08 AM
DetailsLast Recertification DateUpdateRecertification8/25/2023 9:05:49 AM9/6/2024 10:01:54 AM9/6/2024 10:01 AM
AddressesShipping AddressDeleteChange RequestELKHART GENERAL HOSPITAL 600 EAST BLVD ELKHART, IN 46514 7/25/2024 1:38 PM
DetailsLast Recertification DateUpdateRecertification9/20/2022 10:34:15 AM8/25/2023 9:05:49 AM8/25/2023 9:05 AM
DetailsLast Recertification DateUpdateRecertification 9/20/2022 10:34:15 AM9/20/2022 10:34 AM
Medicaid BillingNPI: NumberInsertChange Request 14775514896/17/2022 9:30 AM
Medicaid BillingNPI: StateInsertChange Request MI6/17/2022 9:30 AM
Medicaid BillingNPI: NumberInsertChange Request 14775514896/17/2022 9:30 AM
Medicaid BillingNPI: StateInsertChange Request IL6/17/2022 9:30 AM
AddressesShipping AddressInsertChange Request ELKHART GENERAL HOSPITAL 600 EAST BLVD ELKHART, IN 4651411/1/2021 8:47 AM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/11/2021 8:33 AM
Medicaid BillingMedicaid: NumberInsertChange Request 100295480A10/11/2021 8:33 AM
Medicaid BillingMedicaid: StateInsertChange Request IN10/11/2021 8:33 AM
Medicaid BillingNPI: NumberInsertChange Request 113412870510/11/2021 8:33 AM
Medicaid BillingNPI: StateInsertChange Request IN10/11/2021 8:33 AM
DetailsStateUpdate ApprovedActive10/1/2021 12:01 AM
ContactsSigned ByInsertNew Registration COSTELLO, JEFFREY P. CFO Memorial Hospital of South Bend 57464735497/30/2021 8:48 AM
Details340B IDUpdateNew Registration RRC150018-007/30/2021 8:48 AM
DatesParticipating Approval DateUpdateNew Registration 7/30/2021 8:48:42 AM7/30/2021 8:48 AM
DetailsStateUpdateNew RegistrationPendingApproved7/30/2021 8:48 AM
DatesSigned By DateUpdateNew Registration 7/15/2021 8:24:44 AM7/30/2021 8:48 AM
DatesStart DateUpdateNew Registration 10/1/2021 12:00:00 AM7/30/2021 8:48 AM
AddressesMain AddressInsertNew Registration  600 EAST BLVD ELKHART, IN 465147/14/2021 4:22 PM
AddressesBilling AddressInsertNew Registration Beacon Health System, Inc 615 N Michigan St South Bend, IN 466017/14/2021 4:22 PM
Medicaid BillingMedicaid: Is PrimaryInsertNew Registration False7/14/2021 4:22 PM
Medicaid BillingMedicaid: NumberInsertNew Registration 100268340A7/14/2021 4:22 PM
Medicaid BillingMedicaid: StateInsertNew Registration IN7/14/2021 4:22 PM
Medicaid BillingNPI: NumberInsertNew Registration 14775514897/14/2021 4:22 PM
Medicaid BillingNPI: StateInsertNew Registration IN7/14/2021 4:22 PM
ContactsAuthorizing OfficialInsertNew Registration COSTELLO, JEFFREY P. CFO Memorial Hospital of South Bend 57464735497/14/2021 4:22 PM
ContactsPrimary ContactInsertNew Registration Kaczmarek, Holly Director of Pharmacy Beacon Health System-Elkhart General Hospital 57452334477/14/2021 4:22 PM
DetailsAssistance Received From DateInsertNew Registration  7/14/2021 4:22 PM
DetailsAssistance Received To DateInsertNew Registration  7/14/2021 4:22 PM
DetailsLast Recertification DateInsertNew Registration  7/14/2021 4:22 PM
DetailsGrant NumberInsertNew Registration  7/14/2021 4:22 PM
Details340B IDInsertNew Registration  7/14/2021 4:22 PM
DetailsIs Authorizing Official EHB DataInsertNew Registration  7/14/2021 4:22 PM
DatesLast Date That 340B Drugs PurchasedInsertNew Registration  7/14/2021 4:22 PM
DetailsMedicare Provider NumberInsertNew Registration 1500187/14/2021 4:22 PM
DetailsEntity NameInsertNew Registration ELKHART GENERAL HOSPITAL7/14/2021 4:22 PM
DetailsNOFO NumberInsertNew Registration  7/14/2021 4:22 PM
DetailsProgram CodeInsertNew Registration RRC7/14/2021 4:22 PM
DetailsEntity SubnameInsertNew Registration  7/14/2021 4:22 PM
DatesParticipating Approval DateInsertNew Registration  7/14/2021 4:22 PM
DetailsStateInsertNew Registration Pending7/14/2021 4:22 PM
DatesRegistration DateInsertNew Registration 7/14/2021 4:22:48 PM7/14/2021 4:22 PM
DatesSigned By DateInsertNew Registration  7/14/2021 4:22 PM
DatesStart DateInsertNew Registration  7/14/2021 4:22 PM
TerminationsTermination CommentsInsertNew Registration  7/14/2021 4:22 PM
TerminationsTermination DateInsertNew Registration  7/14/2021 4:22 PM
TerminationsTermination Effective DateInsertNew Registration  7/14/2021 4:22 PM
TerminationsTermination ReasonInsertNew Registration  7/14/2021 4:22 PM