Covered Entity Details

RRC520066-04 MERCY HEALTH SYSTEM CORPORATION (Active) - information as of 5/11/2025 11:51:52 PM

Main Details

Name

MERCY HEALTH SYSTEM CORPORATION

Subdivision Name

MERCY HEALTH MALL - MHJ Occ Conditioning - MHJ Occ Conditioning

Type

Rural Referral Center

Rural

Yes

340B ID

RRC520066-04

Medicare Provider Number

520066

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/16/2023

Participating Start Date

1/1/2024

Participating Approval Date

12/1/2023

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Mercy Health
Shannon Dunphy-Alexander, Senior Vice President / CFO
(608) 757-3126

Primary Contact

Mercyhealth
Clark Montgomery, System Manager of Pharmacy Business and 340B Program
(406) 698-8719

Addresses

Street Address

1010N Washington St 109
JANESVILLE, WI 53548-1500

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
WI	11011400,32796500	1093768962,1598718603
IL	390816848001,390816848401	1093768962,1598718603

Shipping Addresses

Shipping Address 1

MERCY HEALTH SYSTEM CORPORATION
1000 MINERAL POINT AVENUE
JANESVILLE, WI 53548

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
RRC520066-01	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - Mall Multispecialty Clinic - Mall Multispecialty Clinic	1010N Washington St 109	JANESVILLE	WI	Active
RRC520066-02	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY BRODHEAD MEDICAL CENTER - Brodhead Family Practice Clinic/Multispecialty - Brodhead Family Practice Clinic/Multispecialty	2310 1ST CENTER AVE	BRODHEAD	WI	Active
RRC520066-03	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East XRay - East XRay	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated
RRC520066-04	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - MHJ Occ Conditioning - MHJ Occ Conditioning	1010N Washington St 109	JANESVILLE	WI	Active
RRC520066-05	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Phys Therapy - Beloit Phys Therapy	2825 PRAIRIE AVE	BELOIT	WI	Active
RRC520066-06	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC NORTH - North Emergency/Urgent Care Dept - North Emergency/Urgent Care Dept	3400 DEERFIELD DR	JANESVILLE	WI	Active
RRC520066-07	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Urgent Care Clinic - East Urgent Care Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-08	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY TERRACE - Terrace General Surgery Clinic - Terrace General Surgery Clinic	510N TERRACE ST	JANESVILLE	WI	Active
RRC520066-09	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC SOUTH - South Family Practice Clinic/Multispecialty - South Family Practice Clinic/Multispecialty	849 KELLOGG AVE	JANESVILLE	WI	Active
RRC520066-10	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - MHJ Rehab Psychologist - MHJ Rehab Psychologist	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Active
RRC520066-11	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY SPORTS MEDICINE WHITEWATER - Whitewater Sports Medicine Clinic - Whitewater Sports Medicine Clinic	519W MAIN ST	WHITEWATER	WI	Active
RRC520066-12	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Orthopedics Clinic - East Orthopedics Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-13	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE - SLEEP C - MHJ Sleep Center - MHJ Sleep Center	903 MINERAL POINT AVENUE	JANESVILLE	WI	Active
RRC520066-14	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC NORTH - North Multispecialty Clinic - North Multispecialty Clinic	3400 DEERFIELD DR	JANESVILLE	WI	Active
RRC520066-15	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Podiatry Clinic - Beloit Podiatry Clinic	2825 PRAIRIE AVE	BELOIT	WI	Active
RRC520066-16	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH SYSTEM CORPORATION - MHJ Day Addictions - MHJ Day Addictions	903 MINERAL POINT AVE	JANESVILLE	WI	Active
RRC520066-17	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY EDGERTON MEDICAL CENTER - Edgerton Family Practice Clinic/Multispecialty - Edgerton Family Practice Clinic/Multispecialty	217N MAIN ST	EDGERTON	WI	Active
RRC520066-18	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Podiatry Clinic - East Podiatry Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-19	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY WHITEWATER MEDICAL CENTER - Whitewater Family Practice Clinic - Whitewater Family Practice Clinic	507W MAIN ST	WHITEWATER	WI	Active
RRC520066-20	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH SYSTEM CORPORATION - OP Hemodialysis - OP Hemodialysis	903 MINERAL POINT AVE	JANESVILLE	WI	Active
RRC520066-21	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Pediatrics Clinic - Beloit Pediatrics Clinic	2825 PRAIRIE AVE	BELOIT	WI	Active
RRC520066-22	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Family Practice Clinic - East Family Practice Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-23	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC NORTH - North Radiology - North Radiology	3400 DEERFIELD DR	JANESVILLE	WI	Terminated
RRC520066-24	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit XRay - Beloit XRay	2825 PRAIRIE AVE	BELOIT	WI	Terminated
RRC520066-25	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY MILTON MEDICAL CENTER - Milton Phys Therapy - Milton Phys Therapy	725S JANESVILLE ST	MILTON	WI	Active
RRC520066-26	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - MHJ Phys Therapy - MHJ Phys Therapy	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Active
RRC520066-27	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - MHJ Occ Therapy - MHJ Occ Therapy	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Active
RRC520066-28	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - Mall Diabetic Center - Mall Diabetic Center	1010N WASHINGTON ST 109	JANESVILLE	WI	Active
RRC520066-29	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Orthotics - East Orthotics	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-30	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY DELAVAN MEDICAL CENTER - Delavan Family Practice Clinic/Multispecialty - Delavan Family Practice Clinic/Multispecialty	1038E GENEVA ST	DELAVAN	WI	Active
RRC520066-31	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - Mall Optical Clinic - Mall Optical Clinic	1010N Washington St 109	JANESVILLE	WI	Active
RRC520066-32	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Audiology Clinic - East Audiology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-33	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Optical Clinic - East Optical Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-34	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - Sports Medicine Clinic - Sports Medicine Clinic	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Active
RRC520066-35	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Phys/Occ Therapy - East Phys/Occ Therapy	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-36	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Dermatology Clinic - East Dermatology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-37	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - Hand Clinic - Hand Clinic	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Active
RRC520066-38	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY EVANSVILLE MEDICAL CENTER - Evansville Family Practice Clinic/Multispecialty - Evansville Family Practice Clinic/Multispecialty	300 UNION ST	EVANSVILLE	WI	Active
RRC520066-39	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Pediatrics Clinic - East Pediatrics Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-40	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH SYSTEM CORPORATION - MHJ Child Day Trmnt - MHJ Child Day Trmnt	1000 MINERAL POINT AVE	JANESVILLE	WI	Terminated
RRC520066-41	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY LAKE GENEVA MEDICAL CENTER - Lake Geneva Multispecialty Clinic - Lake Geneva Multispecialty Clinic	350 PELLER RD	LAKE GENEVA	WI	Active
RRC520066-42	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HEALTH MALL - MHJ Cardiac Rehab - Cardiac Rehab	1010N Washington St 109	Janesville	WI	Active
RRC520066-43	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY HOSPITAL JANESVILLE-PHYSICAL - Physiatry Clinic - Physiatry Clinic	557 NORTH WASHINGTON STREET	JANESVILLE	WI	Active
RRC520066-44	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East ENT Clinic - East ENT Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-45	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Ophthalmology Clinic - East Ophthalmology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-46	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Endocrinology Clinic - East Endocrinology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-47	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY MILTON MEDICAL CENTER - Milton Family Practice Clinic/Multispecialty - Milton Family Practice Clinic/Multispecialty	725S JANESVILLE ST	MILTON	WI	Active
RRC520066-48	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Rheumatology Clinic - East Rheumatology Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-49	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Allergy Clinic - East Allergy Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-50	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - East Internal Medicine Clinic - East Internal Medicine Clinic	3524E MILWAUKEE ST	JANESVILLE	WI	Active
RRC520066-51	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY ELKHORN MEDICAL CENTER - Elkhorn Multispecialty Clinic - Elkhorn Multispecialty Clinic	839N WISCONSIN ST	ELKHORN	WI	Active
RRC520066-52	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit Family Practice Clinic/Multispecialty - Beloit Family Practice Clinic/Multispecialty	2825 PRAIRIE AVE	BELOIT	WI	Active
RRC520066-53	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY BELOIT MEDICAL CENTER - Beloit OB Gyn Clinic - Beloit OB Gyn Clinic	2825 PRAIRIE AVE	BELOIT	WI	Active
RRC520066-54	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY EVANSVILLE MEDICAL CENTER - Behavioral Health Evansville	300 UNION ST	EVANSVILLE	WI	Active
RRC520066-55	Child	RRC	MERCY HEALTH SYSTEM CORPORATION	MERCY CLINIC EAST - Behavioral Health East	3524E MILWAUKEE ST	JANESVILLE	WI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Montgomery, Clark Pharmacy 340B Manager Mercyhealth 4066988719	Montgomery, Clark System Manager of Pharmacy Business and 340B Program Mercyhealth 4066988719	2/27/2025 12:55 PM
Contacts	Authorizing Official	Update	Change Request	Anderson, Todd Vice President Finance Mercyhealth 8159716738	Dunphy-Alexander, Shannon Senior Vice President / CFO Mercy Health 6087573126	1/13/2025 10:00 AM
Details	Last Recertification Date	Update	Recertification		8/29/2024 2:51:15 PM	8/29/2024 2:51 PM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Anderson, Todd Vice President Finance Mercyhealth 8159716738	12/1/2023 7:24 AM
Details	340B ID	Update	New Registration		RRC520066-04	12/1/2023 7:24 AM
Details	Entity Subname	Update	New Registration	MERCY HEALTH MALL - MHJ Occ Conditioning	MERCY HEALTH MALL - MHJ Occ Conditioning - MHJ Occ Conditioning	12/1/2023 7:24 AM
Dates	Participating Approval Date	Update	New Registration		12/1/2023 7:24:31 AM	12/1/2023 7:24 AM
Details	State	Update	New Registration	Pending	Approved	12/1/2023 7:24 AM
Dates	Signed By Date	Update	New Registration		10/16/2023 4:39:01 PM	12/1/2023 7:24 AM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	12/1/2023 7:24 AM
Addresses	Main Address	Insert	New Registration		1010N Washington St 109 JANESVILLE, WI 53548-1500	10/16/2023 1:50 PM
Addresses	Shipping Address	Insert	New Registration		MERCY HEALTH SYSTEM CORPORATION 1000 MINERAL POINT AVENUE JANESVILLE, WI 53548	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		11011400	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		32796500	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		390816848001	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		390816848401	10/16/2023 1:50 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	10/16/2023 1:50 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093768962	10/16/2023 1:50 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	10/16/2023 1:50 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1598718603	10/16/2023 1:50 PM
Medicaid Billing	NPI: State	Insert	New Registration		WI	10/16/2023 1:50 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093768962	10/16/2023 1:50 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/16/2023 1:50 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1598718603	10/16/2023 1:50 PM
Medicaid Billing	NPI: State	Insert	New Registration		IL	10/16/2023 1:50 PM
Contacts	Authorizing Official	Insert	New Registration		Anderson, Todd Vice President Finance Mercyhealth 8159716738	10/16/2023 1:50 PM
Contacts	Primary Contact	Insert	New Registration		Montgomery, Clark Pharmacy 340B Manager Mercyhealth 4066988719	10/16/2023 1:50 PM
Details	Assistance Received From Date	Insert	New Registration			10/16/2023 1:50 PM
Details	Assistance Received To Date	Insert	New Registration			10/16/2023 1:50 PM
Details	Last Recertification Date	Insert	New Registration			10/16/2023 1:50 PM
Details	Grant Number	Insert	New Registration			10/16/2023 1:50 PM
Details	340B ID	Insert	New Registration			10/16/2023 1:50 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/16/2023 1:50 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/16/2023 1:50 PM
Details	Medicare Provider Number	Insert	New Registration		520066	10/16/2023 1:50 PM
Details	Entity Name	Insert	New Registration		MERCY HEALTH SYSTEM CORPORATION	10/16/2023 1:50 PM
Details	NOFO Number	Insert	New Registration			10/16/2023 1:50 PM
Details	Program Code	Insert	New Registration		RRC	10/16/2023 1:50 PM
Details	Entity Subname	Insert	New Registration		MERCY HEALTH MALL - MHJ Occ Conditioning	10/16/2023 1:50 PM
Dates	Participating Approval Date	Insert	New Registration			10/16/2023 1:50 PM
Details	State	Insert	New Registration		Pending	10/16/2023 1:50 PM
Dates	Registration Date	Insert	New Registration		10/16/2023 1:50:39 PM	10/16/2023 1:50 PM
Dates	Signed By Date	Insert	New Registration			10/16/2023 1:50 PM
Dates	Start Date	Insert	New Registration			10/16/2023 1:50 PM
Terminations	Termination Comments	Insert	New Registration			10/16/2023 1:50 PM
Terminations	Termination Date	Insert	New Registration			10/16/2023 1:50 PM
Terminations	Termination Effective Date	Insert	New Registration			10/16/2023 1:50 PM
Terminations	Termination Reason	Insert	New Registration			10/16/2023 1:50 PM