Covered Entity Details

DSH230081 MUNSON HEALTHCARE CADILLAC HOSPITAL (Active) - information as of 6/6/2025 4:24:44 AM

Main Details

Name

MUNSON HEALTHCARE CADILLAC HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH230081

Medicare Provider Number

230081

Additional Details

Current Program Status

Active

Registration Date

1/14/2022

Participating Start Date

4/1/2022

Participating Approval Date

2/23/2022

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

400 HOBART ST
CADILLAC, MI 49601

Billing Address

Northern Michigan Supply Alliance
Munson Healthcare Cadillac Hospital
PO Box 669
Traverse City, MI 49685

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	1841696754	1841696754

Shipping Addresses

Shipping Address 1

Munson Healthcare Cadillac Hospital
850 Lester Street
Cadillac, MI 49601

Shipping Address 2

Munson Healthcare Cadillac Hospital
400 Hobart Street
Cadillac, MI 49601

Shipping Address 3

Munson Infusion Pharmacy
217 S MADISON STREET
COWELL FAMILY CANCER CENTER
TRAVERSE CITY, MI 49684-2386

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	02/23/2022	04/01/2022		04/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	02/23/2022	04/01/2022		04/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/16/2023	04/01/2023		04/01/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	02/23/2022	04/01/2022		04/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	02/23/2022	04/01/2022		04/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	02/23/2022	04/01/2022	06/30/2023	06/30/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	10/10/2024	01/01/2025		01/01/2025
Contract Detail	CADILLAC FAMILY PHARMACY, LLC	108 N MITCHELL ST		CADILLAC	MI	49601-2713	02/23/2022	04/01/2022	02/05/2024	02/05/2024
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	02/23/2022	04/01/2022	07/28/2022	07/29/2022
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	02/23/2022	04/01/2022		04/01/2022
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	02/23/2022	04/01/2022		04/01/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	02/23/2022	04/01/2022		04/01/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	02/23/2022	04/01/2022		04/01/2022
Contract Detail	FAMILY FARE	FAMILY FARE PHARMACY #648	602 S MITCHELL ST	CADILLAC	MI	49601	02/23/2022	04/01/2022		04/01/2022
Contract Detail	LC FAMILY PHARMACY	57 N MOREY RD		LAKE CITY	MI	49651	02/23/2022	04/01/2022		04/01/2022
Contract Detail	MCBAIN FAMILY PHARMACY	119 N ROLAND ST		MC BAIN	MI	49657	02/23/2022	04/01/2022		04/01/2022
Contract Detail	MEIJER DISTRIBUTION INC #90	2721 WALKER AVE NW		GRAND RAPIDS	MI	49544	02/23/2022	04/01/2022		04/01/2022
Contract Detail	MEIJER INC #171	8605 EAST 34 ROAD		CADILLAC	MI	49601	02/23/2022	04/01/2022		04/01/2022
Contract Detail	MEIJER PHARMACY #464	41255 COCA COLA DR.		BELLEVILLE	MI	48111-1827	02/23/2022	04/01/2022		04/01/2022
Contract Detail	MEIJER STORES LIMITED PARTNERSHIP	D/B/A MEIJER PHARMACY #463	1515 PROFIT DR.	FORT WAYNE	IN	46808	02/23/2022	04/01/2022		04/01/2022
Contract Detail	MUNSON HEALTHCARE SPECIALTY PHARMACY	550 MUNSON AVE UNIT 4		TRAVERSE CITY	MI	49686	07/17/2023	10/01/2023		10/01/2023
Contract Detail	MUNSON HOSPITAL PHARMACY	1105 SIXTH ST		TRAVERSE CITY	MI	49684	10/10/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	10/10/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/29/2022	08/01/2022		08/01/2022
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/10/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	01/19/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	02/23/2022	04/01/2022		04/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/10/2024	01/01/2025		01/01/2025
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	02/23/2022	04/01/2022		04/01/2022
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4506	720 SOUTH MITCHELL STREET	CADILLAC	MI	49601	02/23/2022	04/01/2022	07/31/2024	07/31/2024
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	04/17/2023	07/01/2023		07/01/2023
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/17/2023	07/01/2023		07/01/2023
Contract Detail	SORKIN'S RX LTD	D/B/A CAREMED PHARMACEUTICAL SERVICES	1985 MARCUS AVE STE 130	NEW HYDE PARK	NY	11042-2024	04/17/2023	07/01/2023		07/01/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	02/23/2022	04/01/2022		04/01/2022
Contract Detail	WAL-MART PHARMACY 10-1432	8917 EAST 34 ROAD		CADILLAC	MI	49601	02/23/2022	04/01/2022		04/01/2022
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	02/23/2022	04/01/2022		04/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07660	1220 N MITCHELL	CADILLAC	MI	49601-1261	02/23/2022	04/01/2022		04/01/2022
Contract Detail	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	10/16/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	02/23/2022	04/01/2022		04/01/2022
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/16/2023	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH230081A	Child	DSH	MUNSON HEALTHCARE CADILLAC HOSPITAL	MUNSON HEALTHCARE CADILLAC - Urgent Care	302 HOBART ST	CADILLAC	MI	Active
DSH230081B	Child	DSH	MUNSON HEALTHCARE CADILLAC HOSPITAL	MUNSON HEALTHCARE CADILLAC - MCBAIN PRIMARY CARE	100 N ROLAND ST	MCBAIN	MI	Active
DSH230081C	Child	DSH	MUNSON HEALTHCARE CADILLAC HOSPITAL	MUNSON HEALTHCARE CADILLAC - Cadillac OB/GYN	7985 MACKINAW TRL	CADILLAC	MI	Active
DSH230081D	Child	DSH	MUNSON HEALTHCARE CADILLAC HOSPITAL	MUNSON HEALTHCARE CADILLAC - Cadillac Primary Care	7985 MACKINAW TRL	CADILLAC	MI	Active
DSH230081E	Child	DSH	MUNSON HEALTHCARE CADILLAC HOSPITAL	MUNSON HEALTHCARE CADILLAC - Manistee Cancer & Infusion Center	1465 E PARKDALE AVE	MANISTEE	MI	Active
DSH230081F	Child	DSH	MUNSON HEALTHCARE CADILLAC HOSPITAL	Traverse Heart & Vascular - Cadillac - Heart and Vascular	704 Oak Street	Cadillac	MI	Active
DSH230081G	Child	DSH	MUNSON HEALTHCARE CADILLAC HOSPITAL	MUNSON HEALTHCARE CADILLAC - Cancer & Infusion Center	217 S Madison Street	Traverse City	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/15/2023 9:41:45 AM	8/20/2024 9:34:08 AM	8/20/2024 9:34 AM
Addresses	Shipping Address	Insert	Change Request		Munson Infusion Pharmacy 217 S MADISON STREET COWELL FAMILY CANCER CENTER TRAVERSE CITY, MI 49684-2386	5/31/2024 8:49 PM
Details	Last Recertification Date	Update	Recertification	8/29/2022 9:29:16 AM	8/15/2023 9:41:45 AM	8/15/2023 9:41 AM
Contacts	Authorizing Official	Update	Change Request	Maly, Kathleen Maly Interim Chief Financial Officer Munson Healthcare 2488851252	LaRaia, Kathleen M Vice President Munson Healthcare 2313928410	3/22/2023 12:13 PM
Details	Last Recertification Date	Update	Recertification		8/29/2022 9:29:16 AM	8/29/2022 9:29 AM
Contacts	Authorizing Official	Update	Change Request	Maitland, Alicia CFO Munson Healthcare 2319357840	Maly, Kathleen Maly Interim Chief Financial Officer Munson Healthcare 2488851252	8/2/2022 7:50 AM
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		Approved	Active	4/1/2022 12:01 AM
Contacts	Signed By	Update	Hospital Type Change Request	Boyer, David A. CFO 2318767401	Maitland, Alicia CFO Munson Healthcare 2319357840	2/23/2022 12:56 PM
Details	340B ID	Update	Hospital Type Change Request		DSH230081	2/23/2022 12:56 PM
Dates	Participating Approval Date	Update	Hospital Type Change Request		2/23/2022 12:56:07 PM	2/23/2022 12:56 PM
Details	State	Update	Hospital Type Change Request	Pending	Approved	2/23/2022 12:56 PM
Dates	Signed By Date	Update	Hospital Type Change Request		2/22/2022 12:19:04 PM	2/23/2022 12:56 PM
Dates	Start Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	2/23/2022 12:56 PM
Addresses	Main Address	Insert	Hospital Type Change Request		400 HOBART ST CADILLAC, MI 49601	1/14/2022 7:53 AM
Addresses	Billing Address	Insert	Hospital Type Change Request		Northern Michigan Supply Alliance Munson Healthcare Cadillac Hospital PO Box 669 Traverse City, MI 49685	1/14/2022 7:53 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		Munson Healthcare Cadillac Hospital 850 Lester Street Cadillac, MI 49601	1/14/2022 7:53 AM
Addresses	Shipping Address	Insert	Hospital Type Change Request		Munson Healthcare Cadillac Hospital 400 Hobart Street Cadillac, MI 49601	1/14/2022 7:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Hospital Type Change Request		False	1/14/2022 7:53 AM
Medicaid Billing	Medicaid: Number	Insert	Hospital Type Change Request		1841696754	1/14/2022 7:53 AM
Medicaid Billing	Medicaid: State	Insert	Hospital Type Change Request		MI	1/14/2022 7:53 AM
Medicaid Billing	NPI: Number	Insert	Hospital Type Change Request		1841696754	1/14/2022 7:53 AM
Medicaid Billing	NPI: State	Insert	Hospital Type Change Request		MI	1/14/2022 7:53 AM
Contacts	Primary Contact	Insert	Hospital Type Change Request		Niemi, Sam Patrick Manager Reimbursement Munson Healthcare 2319357761	1/14/2022 7:53 AM
Contacts	Authorizing Official	Insert	Hospital Type Change Request		Maitland, Alicia CFO Munson Healthcare 2319357840	1/14/2022 7:53 AM
Contacts	Signed By	Insert	Hospital Type Change Request		Boyer, David A. CFO 2318767401	1/14/2022 7:53 AM
Details	Assistance Received From Date	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Details	Assistance Received To Date	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Details	Last Recertification Date	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Details	Grant Number	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Details	340B ID	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Details	Is Authorizing Official EHB Data	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Dates	Last Date That 340B Drugs Purchased	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Details	Medicare Provider Number	Insert	Hospital Type Change Request		230081	1/14/2022 7:53 AM
Details	Entity Name	Insert	Hospital Type Change Request		MUNSON HEALTHCARE CADILLAC HOSPITAL	1/14/2022 7:53 AM
Details	NOFO Number	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Details	Program Code	Insert	Hospital Type Change Request		DSH	1/14/2022 7:53 AM
Details	Entity Subname	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Dates	Participating Approval Date	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Details	State	Insert	Hospital Type Change Request		Pending	1/14/2022 7:53 AM
Dates	Registration Date	Insert	Hospital Type Change Request		1/14/2022 7:53:49 AM	1/14/2022 7:53 AM
Dates	Signed By Date	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Dates	Start Date	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Terminations	Termination Comments	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Terminations	Termination Date	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Terminations	Termination Effective Date	Insert	Hospital Type Change Request			1/14/2022 7:53 AM
Terminations	Termination Reason	Insert	Hospital Type Change Request			1/14/2022 7:53 AM