Grant Number
Site ID
Medicare Provider Number
Outpatient Facility Provider Number
340B ID
Current Program Status
Entity Type
Registration Date
Participating
Participating Start Date
Participating Approval Date
Termination Code
Termination Date
Last Recertification Date
CE ID
Parent CE ID
NOFO Number
Assistance Received From Date
Assistance Received To Date
Entity Name
Entity Sub-Division Name

Primary Contact Name
Primary Contact Title
Primary Contact Telephone
Primary Contact Extension

Pharmacy Name *
Address 1 *
Address 2 *
Address 3 *
City *
State *
Zip *
Second Zip *
Contract ID *
Contract Begin Date *
Contract Approval Date *
Contract Term Date *
Pharmacy Comments *
Pharmacy ID *
Medicaid Billing *
Carve-In Effective Date *

Address 1
Address 2
Address 3
City
State
Zip
Second Zip

Medicaid Number
NPI

Nature Of Support *
InKind Support Description *
Support Received From Date *
Support Received To Date *

Signed By Name
Signed By Title
Signed By Date
Signed By Telephone
Signed By Extension

Contract Pharmacy Rep Name *
Contract Pharmacy Rep Title *
Contract Pharmacy Rep Telephone *
Contract Pharmacy Rep Extension *

Billing Organization
Address 1
Address 2
Address 3
City
State
Zip
Second Zip

Shipping Organization *
Address 1 *
Address 2 *
Address 3 *
City *
State *
Zip *
Second Zip *

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

Rural
Public Comments
Edit Date