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DSH520066 MERCY HEALTH SYSTEM CORPORATION (Terminated)
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Main Details
Name
MERCY HEALTH SYSTEM CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH520066
Medicare Provider Number
520066
Additional Details
Current Program Status
Terminated
Registration Date
1/10/2019
Participating Start Date
4/1/2019
Participating Approval Date
2/7/2019
Last Recertification Date
8/30/2023
Termination Date
Termination Reason
1/1/2024
Change of covered entity type
Contacts
Authorizing Official
Mercyhealth
Todd Anderson, Vice President Finance
(815) 971-6738
Primary Contact
Mercyhealth
Clark Montgomery, System Manager of Pharmacy Business and 340B Program
(406) 698-8719
Addresses
Street Address
1000 MINERAL POINT AVE
JANESVILLE, WI 53547-5003
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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