Covered Entity Details

RRC230216-04 MCLAREN PORT HURON (Terminated) - information as of 5/9/2025 12:15:02 AM

Main Details

Name

MCLAREN PORT HURON

Subdivision Name

MCLAREN PORT HURON FAMILY MEDICINE - Primary Care / Internal Medicine

Type

Rural Referral Center

Rural

340B ID

RRC230216-04

Medicare Provider Number

230216

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

12/1/2021

Participating Start Date

12/7/2021

Participating Approval Date

12/7/2021

Last Recertification Date

8/26/2024

Termination Date
Termination Reason

1/1/2025
Site closure

Contacts

Authorizing Official

McLaren Port Huron
Kyle Vining, McLaren Port Huron CFO
(810) 989-3749

Primary Contact

McLaren Health Care
Tiffany Harwood, Corporate Director of 340B Data Analytics
(734) 512-8778

Addresses

Street Address

1216 RICHARDSON ST
PORT HURON, MI 48060

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
MI	1619355930,1386888170,1982685384	1619355930,1386888170,1982685384

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
RRC230216-01	Child	RRC	MCLAREN PORT HURON	MCLAREN PORT HURON CENTER FOR CARDIOVASCULAR & THORACIC SURGERY - CARDIO & THORACIC SURGERY	1117 STONE ST	PORT HURON	MI	Active
RRC230216-02	Child	RRC	MCLAREN PORT HURON	MCLAREN PORT HURON PULMONOLOGY, CRITICAL CARE AND SLEEP MEDICINE - SLEEP CLINIC	1231 PINE GROVE AVE	PORT HURON	MI	Active
RRC230216-03	Child	RRC	MCLAREN PORT HURON	MCLAREN PORT HURON ADVANCED ORTHOPEDICS - ORTHOPEDIC SURGEON	1231 PINE GROVE AVE	PORT HURON	MI	Active
RRC230216-04	Child	RRC	MCLAREN PORT HURON	MCLAREN PORT HURON FAMILY MEDICINE - Primary Care / Internal Medicine	1216 RICHARDSON ST	PORT HURON	MI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/31/2024 12:00:00 AM	10/7/2024 10:15 AM
Details	State	Update	Termination Request	Active	To Be Terminated	10/7/2024 10:15 AM
Terminations	Termination Date	Update	Termination Request		1/1/2025 12:00:00 AM	10/7/2024 10:15 AM
Terminations	Termination Effective Date	Update	Termination Request		8/1/2024 12:00:00 AM	10/7/2024 10:15 AM
Terminations	Termination Reason	Update	Termination Request		Site closure	10/7/2024 10:15 AM
Details	Last Recertification Date	Update	Recertification	8/18/2023 11:49:53 AM	8/26/2024 10:58:41 AM	8/26/2024 10:58 AM
Contacts	Authorizing Official	Update	Profile Change Request	Vining, Kyle McLaren Macomb CFO McLaren Macomb 8109893749	Vining, Kyle McLaren Port Huron CFO McLaren Port Huron 8109893749	3/13/2024 2:34 PM
Contacts	Primary Contact	Update	PC Change Request	Vandeusen, Kellie Renee Regional Director of Reimbursement McLaren Flint 8103422876	Harwood, Tiffany Corporate Director of 340B Data Analytics McLaren Health Care 7345128778	2/28/2024 7:57 AM
Contacts	Authorizing Official	Update	Change Request	Brown, Sharelle Corporate, 340B Program Director McLaren Health Care 2483968085	Vining, Kyle McLaren Macomb CFO McLaren Macomb 8109893749	2/26/2024 12:51 PM
Details	Last Recertification Date	Update	Recertification	8/31/2022 1:16:19 PM	8/18/2023 11:49:53 AM	8/18/2023 11:49 AM
Contacts	Authorizing Official	Update	AO Change Request	Balutanski, Brian Regional CFO McLaren Macomb 5864933044	Brown, Sharelle Corporate, 340B Program Director McLaren Health Care 2483968085	12/13/2022 5:45 PM
Details	Last Recertification Date	Update	Recertification		8/31/2022 1:16:19 PM	8/31/2022 1:16 PM
Contacts	Authorizing Official	Update	Change Request	Sholtis, Bridget Ann CFO McLaren Port Huron 8109893749	Balutanski, Brian Regional CFO McLaren Macomb 5864933044	3/25/2022 10:41 AM
Details	State	Update	OPA Edit	Approved	Active	12/7/2021 8:54 AM
Dates	Start Date	Update	OPA Edit	1/1/2022 12:00:00 AM	12/7/2021 12:00:00 AM	12/7/2021 8:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	12/7/2021 8:46 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1386888170	12/7/2021 8:46 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	12/7/2021 8:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	12/7/2021 8:46 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1982685384	12/7/2021 8:46 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	12/7/2021 8:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1386888170	12/7/2021 8:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	12/7/2021 8:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1982685384	12/7/2021 8:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	12/7/2021 8:46 AM
Contacts	Signed By	Insert	New Registration		Sholtis, Bridget Ann CFO McLaren Port Huron 8109893749	12/7/2021 8:46 AM
Details	340B ID	Update	New Registration		RRC230216-04	12/7/2021 8:46 AM
Details	Entity Subname	Update	New Registration	MCLAREN PORT HURON FAMILY MEDICINE	MCLAREN PORT HURON FAMILY MEDICINE - Primary Care / Internal Medicine	12/7/2021 8:46 AM
Dates	Participating Approval Date	Update	New Registration		12/7/2021 8:46:48 AM	12/7/2021 8:46 AM
Details	State	Update	New Registration	Pending	Approved	12/7/2021 8:46 AM
Dates	Signed By Date	Update	New Registration		12/2/2021 4:42:22 PM	12/7/2021 8:46 AM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	12/7/2021 8:46 AM
Addresses	Main Address	Insert	New Registration		1216 RICHARDSON ST PORT HURON, MI 48060	12/1/2021 5:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	12/1/2021 5:55 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1619355930	12/1/2021 5:55 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MI	12/1/2021 5:55 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1619355930	12/1/2021 5:55 PM
Medicaid Billing	NPI: State	Insert	New Registration		MI	12/1/2021 5:55 PM
Contacts	Primary Contact	Insert	New Registration		Vandeusen, Kellie Renee Regional Director of Reimbursement McLaren Flint 8103422876	12/1/2021 5:55 PM
Contacts	Authorizing Official	Insert	New Registration		Sholtis, Bridget Ann CFO McLaren Port Huron 8109893749	12/1/2021 5:55 PM
Details	Assistance Received From Date	Insert	New Registration			12/1/2021 5:55 PM
Details	Assistance Received To Date	Insert	New Registration			12/1/2021 5:55 PM
Details	Last Recertification Date	Insert	New Registration			12/1/2021 5:55 PM
Details	Grant Number	Insert	New Registration			12/1/2021 5:55 PM
Details	340B ID	Insert	New Registration			12/1/2021 5:55 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			12/1/2021 5:55 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			12/1/2021 5:55 PM
Details	Medicare Provider Number	Insert	New Registration		230216	12/1/2021 5:55 PM
Details	Entity Name	Insert	New Registration		MCLAREN PORT HURON	12/1/2021 5:55 PM
Details	NOFO Number	Insert	New Registration			12/1/2021 5:55 PM
Details	Program Code	Insert	New Registration		RRC	12/1/2021 5:55 PM
Details	Entity Subname	Insert	New Registration		MCLAREN PORT HURON FAMILY MEDICINE	12/1/2021 5:55 PM
Dates	Participating Approval Date	Insert	New Registration			12/1/2021 5:55 PM
Details	State	Insert	New Registration		Pending	12/1/2021 5:55 PM
Dates	Registration Date	Insert	New Registration		12/1/2021 5:55:46 PM	12/1/2021 5:55 PM
Dates	Signed By Date	Insert	New Registration			12/1/2021 5:55 PM
Dates	Start Date	Insert	New Registration			12/1/2021 5:55 PM
Terminations	Termination Comments	Insert	New Registration			12/1/2021 5:55 PM
Terminations	Termination Date	Insert	New Registration			12/1/2021 5:55 PM
Terminations	Termination Effective Date	Insert	New Registration			12/1/2021 5:55 PM
Terminations	Termination Reason	Insert	New Registration			12/1/2021 5:55 PM