Covered Entity Details

RRC520049-00 BELLIN MEMORIAL HOSPITAL (Terminated) - information as of 6/13/2025 2:56:08 PM

Main Details

Name

BELLIN MEMORIAL HOSPITAL

Subdivision Name

Type

Rural Referral Center

Rural

340B ID

RRC520049-00

Medicare Provider Number

520049

Additional Details

Current Program Status

Terminated

Registration Date

10/11/2023

Participating Start Date

1/1/2024

Participating Approval Date

11/21/2023

Last Recertification Date

9/6/2024

Termination Date
Termination Reason

4/1/2025
DSH percentage below statutory minimum

Contacts

Authorizing Official

Bellin Memorial Hospital Inc
Sharla Baenen, Chief Operating Officer
(920) 433-7549

Primary Contact

Bellin Memorial Hospital Inc
Alar Laura, Director of Pharmacy
(920) 433-3635

Addresses

Street Address

744 S WEBSTER AVENUE
GREEN BAY, WI 54301-3400

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

Shipping Address 1

Bellin Memorial Hospital
905 Cass Street
Green Bay, WI 54301

Shipping Address 2

Bellin Memorial Hospital
744 S. Webster Avenue
Green Bay, WI 54301

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	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	BELLIN HEALTH	BELLIN HEALTH PHARMACY	744 S WEBSTER AVE	GREEN BAY	WI	54301-3505	11/21/2023	01/01/2024	04/01/2025	04/01/2025
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/11/2024	10/01/2024	04/01/2025	04/01/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/11/2024	10/01/2024	04/01/2025	04/01/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
RRC520049-01	Child	RRC	BELLIN MEMORIAL HOSPITAL	BELLIN MEMORIAL HOSPITAL INC - Wound Healing	725 S WEBSTER AVE	GREEN BAY	WI	Terminated
RRC520049-02	Child	RRC	BELLIN MEMORIAL HOSPITAL	BELLIN MEMORIAL HOSPITAL INC - Bellin Pain Management	744 S WEBSTER AVE	GREEN BAY	WI	Terminated
RRC520049-03	Child	RRC	BELLIN MEMORIAL HOSPITAL	THE CANCER TEAM AT BELLIN HEALTH - Medical Oncology	1580 COMMANCHE AVE	GREEN BAY	WI	Terminated
RRC520049-04	Child	RRC	BELLIN MEMORIAL HOSPITAL	BELLIN MEMORIAL HOSPITAL INC - Cardiology Associates GB	744 S WEBSTER AVE	GREEN BAY	WI	Terminated
RRC520049-05	Child	RRC	BELLIN MEMORIAL HOSPITAL	BELLIN MEMORIAL HOSPITAL INC - Sleep & Pulmonary Center	744 S WEBSTER AVE	GREEN BAY	WI	Terminated
RRC520049-06	Child	RRC	BELLIN MEMORIAL HOSPITAL	THE CANCER TEAM AT BELLIN HEALTH - Radiation Oncology	1580 COMMANCHE AVE	GREEN BAY	WI	Terminated
RRC520049-07	Child	RRC	BELLIN MEMORIAL HOSPITAL	BELLIN MEMORIAL HOSPITAL INC - Outpatient Infusion Center	1580 COMMANCHE AVE	GREEN BAY	WI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2025 12:01 AM
Contacts	Primary Contact	Update	Profile Change Request	Laura, Alar Director of Pharmacy Bellin Memorial Hosital Inc 9204333635	Laura, Alar Director of Pharmacy Bellin Memorial Hospital Inc 9204333635	3/6/2025 8:13 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/28/2025 12:00:00 AM	3/4/2025 8:26 AM
Details	State	Update	Termination Request	Active	To Be Terminated	3/4/2025 8:26 AM
Terminations	Termination Date	Update	Termination Request		4/1/2025 12:00:00 AM	3/4/2025 8:26 AM
Terminations	Termination Effective Date	Update	Termination Request		3/1/2025 12:00:00 AM	3/4/2025 8:26 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	3/4/2025 8:26 AM
Addresses	Main Address	Update	Recertification	744 S WEBSTER AVENUE GREEN BAY, WI 54305-3400	744 S WEBSTER AVENUE GREEN BAY, WI 54301-3400	9/6/2024 1:04 PM
Addresses	Shipping Address	Delete	Recertification	Bellin Memorial Hospital 744 S. Webster Avenue Green Bay, WI 54305		9/6/2024 1:04 PM
Addresses	Shipping Address	Insert	Recertification		Bellin Memorial Hospital 744 S. Webster Avenue Green Bay, WI 54301	9/6/2024 1:04 PM
Details	Last Recertification Date	Update	Recertification		9/6/2024 1:04:10 PM	9/6/2024 1:04 PM
Addresses	Shipping Address	Insert	Change Request		Bellin Memorial Hospital 744 S. Webster Avenue Green Bay, WI 54305	6/21/2024 11:42 AM
Addresses	Shipping Address	Insert	Change Request		Bellin Memorial Hospital 905 Cass Street Green Bay, WI 54301	6/21/2024 11:42 AM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Baenen, Sharla Chief Operating Officer Bellin Memorial Hospital Inc 9204337549	11/21/2023 4:51 PM
Details	340B ID	Update	New Registration		RRC520049-00	11/21/2023 4:51 PM
Dates	Participating Approval Date	Update	New Registration		11/21/2023 4:51:16 PM	11/21/2023 4:51 PM
Details	State	Update	New Registration	Pending	Approved	11/21/2023 4:51 PM
Dates	Signed By Date	Update	New Registration		11/21/2023 1:52:30 PM	11/21/2023 4:51 PM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	11/21/2023 4:51 PM
Addresses	Main Address	Insert	New Registration		744 S WEBSTER AVENUE GREEN BAY, WI 54305-3400	10/11/2023 11:38 AM
Contacts	Primary Contact	Insert	New Registration		Laura, Alar Director of Pharmacy Bellin Memorial Hosital Inc 9204333635	10/11/2023 11:38 AM
Contacts	Authorizing Official	Insert	New Registration		Baenen, Sharla Chief Operating Officer Bellin Memorial Hospital Inc 9204337549	10/11/2023 11:38 AM
Details	Assistance Received From Date	Insert	New Registration			10/11/2023 11:38 AM
Details	Assistance Received To Date	Insert	New Registration			10/11/2023 11:38 AM
Details	Last Recertification Date	Insert	New Registration			10/11/2023 11:38 AM
Details	Grant Number	Insert	New Registration			10/11/2023 11:38 AM
Details	340B ID	Insert	New Registration			10/11/2023 11:38 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2023 11:38 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2023 11:38 AM
Details	Medicare Provider Number	Insert	New Registration		520049	10/11/2023 11:38 AM
Details	Entity Name	Insert	New Registration		BELLIN MEMORIAL HOSPITAL	10/11/2023 11:38 AM
Details	NOFO Number	Insert	New Registration			10/11/2023 11:38 AM
Details	Program Code	Insert	New Registration		RRC	10/11/2023 11:38 AM
Details	Entity Subname	Insert	New Registration			10/11/2023 11:38 AM
Dates	Participating Approval Date	Insert	New Registration			10/11/2023 11:38 AM
Details	State	Insert	New Registration		Pending	10/11/2023 11:38 AM
Dates	Registration Date	Insert	New Registration		10/11/2023 11:38:03 AM	10/11/2023 11:38 AM
Dates	Signed By Date	Insert	New Registration			10/11/2023 11:38 AM
Dates	Start Date	Insert	New Registration			10/11/2023 11:38 AM
Terminations	Termination Comments	Insert	New Registration			10/11/2023 11:38 AM
Terminations	Termination Date	Insert	New Registration			10/11/2023 11:38 AM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2023 11:38 AM
Terminations	Termination Reason	Insert	New Registration			10/11/2023 11:38 AM