340B Drug Pricing Program Database

Manufacturer ID
Labeler Code
Manufacturer Name
Sub-Division Name
OPA Termination Date
CMS Termination Date
Termination Comments
Termination Reason
Status
Comments

Address 1
Address 2
Address 3
City
State
Zip
Second Zip

Signed By Name
Signed By Title
PPA Signed By Date
Signed By Telephone
Signed By Extension
HRSA PPA Co-Signed Date

Addendum Signed By Name
Addendum Signed By Title
Addendum Signed By Telephone
Addendum Signed By Extension
Addendum Signed Date
HRSA Addendum Co-Signed Date

Contact Name
Contact Title
Contact Telephone
Contact Extension

Authorizing Official Name
Authorizing Official Title
Authorizing Official Telephone
Authorizing Official Extension

Edit Date