Covered Entity Details

CAH141353-00 Iroquois Memorial Hospital (Active) - information as of 4/29/2025 11:58:20 PM

Main Details

Name

Iroquois Memorial Hospital

Subdivision Name

Type

Critical Access Hospital

Rural

340B ID

CAH141353-00

Medicare Provider Number

141353

Additional Details

Current Program Status

Active

Registration Date

10/13/2023

Participating Start Date

1/1/2024

Participating Approval Date

11/14/2023

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Michael Tilstra, CEO
(815) 432-7777

Primary Contact

IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
MICHAEL A SANDSMARK, PHARMACIST
(815) 432-7746

Addresses

Street Address

200 E. Fairman Ave.
Watseka, IL 60970

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
IL	370673512001	1629003470
IN	100037080A	1629003470

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY # 06679	300 E. WALNUT ST.	WATSEKA	IL	60970	11/14/2023	01/01/2024	01/01/2024
Contract Detail	HIGHLAND PARK CVS, L.L.C.	DBA: CVS/PHARMACY #10627	720 S CRESCENT ST	GILMAN	IL	60938	11/14/2023	01/01/2024	01/01/2024
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06670	512 E. SEYMOUR ST.	KENTLAND	IN	47951	11/14/2023	01/01/2024	01/01/2024
Contract Detail	HUDSON DRUG SHOP	108 N MARKET ST	PO BOX 70	PAXTON	IL	60957-1220	07/09/2024	10/01/2024	10/01/2024
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	11/14/2023	01/01/2024	01/01/2024
Contract Detail	WAL-MART PHARMACY 10-1307	2080 N. STATE ROUTE 50		BOURBONNAIS	IL	60914	11/14/2023	01/01/2024	01/01/2024
Contract Detail	WAL-MART PHARMACY 10-1548	1790 EAST WALNUT STREET		WATSEKA	IL	60970	11/14/2023	01/01/2024	01/01/2024
Contract Detail	WAL-MART PHARMACY 10-4323	505 RIVERSTONE PARKWAY		KANKAKEE	IL	60901	11/14/2023	01/01/2024	01/01/2024
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	11/14/2023	01/01/2024	01/01/2024
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	11/14/2023	01/01/2024	01/01/2024
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	11/14/2023	01/01/2024	01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH141353-01	Child	CAH	Iroquois Memorial Hospital	IMH Milford Clinic - IMH Milford Clinic	34 E Jones St	Milford	IL	Active
CAH141353-02	Child	CAH	Iroquois Memorial Hospital	IMH MSP Clinic - IMH MSP Clinic	200 E. Fairman Ave.	Watseka	IL	Active
CAH141353-03	Child	CAH	Iroquois Memorial Hospital	IMH Kentland Clinic - IMH Kentland Clinic	303 N Seventh St	Kentland	IN	Active
CAH141353-04	Child	CAH	Iroquois Memorial Hospital	IMH Gilman Clinic - IMH Gilman Clinic	720 S Crescent St	Gilman	IL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification		8/22/2024 7:50:12 AM	8/22/2024 7:50 AM
Contacts	Authorizing Official	Update	AO Change Request	Bransky, Shawn Chief Financial Officer Iroquois Memorial Hospital 8154327929	Tilstra, Michael CEO IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME 8154327777	8/21/2024 4:11 PM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Bransky, Shawn Chief Financial Officer Iroquois Memorial Hospital 8154327929	11/14/2023 1:42 PM
Details	340B ID	Update	New Registration		CAH141353-00	11/14/2023 1:42 PM
Dates	Participating Approval Date	Update	New Registration		11/14/2023 1:42:47 PM	11/14/2023 1:42 PM
Details	State	Update	New Registration	Pending	Approved	11/14/2023 1:42 PM
Dates	Signed By Date	Update	New Registration		10/20/2023 4:40:10 PM	11/14/2023 1:42 PM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	11/14/2023 1:42 PM
Addresses	Main Address	Insert	New Registration		200 E. Fairman Ave. Watseka, IL 60970	10/13/2023 1:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2023 1:46 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		370673512001	10/13/2023 1:46 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/13/2023 1:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2023 1:46 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100037080A	10/13/2023 1:46 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	10/13/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629003470	10/13/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/13/2023 1:46 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629003470	10/13/2023 1:46 PM
Medicaid Billing	NPI: State	Insert	New Registration		IN	10/13/2023 1:46 PM
Contacts	Primary Contact	Insert	New Registration		SANDSMARK, MICHAEL A PHARMACIST IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME 8154327746	10/13/2023 1:46 PM
Contacts	Authorizing Official	Insert	New Registration		Bransky, Shawn Chief Financial Officer Iroquois Memorial Hospital 8154327929	10/13/2023 1:46 PM
Details	Assistance Received From Date	Insert	New Registration			10/13/2023 1:46 PM
Details	Assistance Received To Date	Insert	New Registration			10/13/2023 1:46 PM
Details	Last Recertification Date	Insert	New Registration			10/13/2023 1:46 PM
Details	Grant Number	Insert	New Registration			10/13/2023 1:46 PM
Details	340B ID	Insert	New Registration			10/13/2023 1:46 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/13/2023 1:46 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/13/2023 1:46 PM
Details	Medicare Provider Number	Insert	New Registration		141353	10/13/2023 1:46 PM
Details	Entity Name	Insert	New Registration		Iroquois Memorial Hospital	10/13/2023 1:46 PM
Details	NOFO Number	Insert	New Registration			10/13/2023 1:46 PM
Details	Program Code	Insert	New Registration		CAH	10/13/2023 1:46 PM
Details	Entity Subname	Insert	New Registration			10/13/2023 1:46 PM
Dates	Participating Approval Date	Insert	New Registration			10/13/2023 1:46 PM
Details	State	Insert	New Registration		Pending	10/13/2023 1:46 PM
Dates	Registration Date	Insert	New Registration		10/13/2023 1:46:46 PM	10/13/2023 1:46 PM
Dates	Signed By Date	Insert	New Registration			10/13/2023 1:46 PM
Dates	Start Date	Insert	New Registration			10/13/2023 1:46 PM
Terminations	Termination Comments	Insert	New Registration			10/13/2023 1:46 PM
Terminations	Termination Date	Insert	New Registration			10/13/2023 1:46 PM
Terminations	Termination Effective Date	Insert	New Registration			10/13/2023 1:46 PM
Terminations	Termination Reason	Insert	New Registration			10/13/2023 1:46 PM