Covered Entity Details

DSH340069BR WAKEMED (Approved) - information as of 5/20/2025 12:52:58 AM

Main Details

Name

WAKEMED

Subdivision Name

WakeMed Wendell Healthplex - Imaging Services - CT Scan - Imaging Services - CT Scan

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340069BR

Medicare Provider Number

340069

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/8/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/3/2025

Last Recertification Date

Contacts

Authorizing Official

Wakemed
DONALD GINTZIG, President and CEO
(919) 350-8102

Primary Contact

Wakemed
Abbie Crisp Williamson, Executive Director of Pharmacy
(919) 350-8240

Addresses

Street Address

2021 Wendell Valley Blvd
Wendell, NC 27591

Billing Address

WakeMed Wendell Healthplex
Attn: Accounts Payable
PO Box 14549
Raleigh, NC 27620

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
NC		1972579837

Shipping Addresses

Same as Street Address

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
DSH340069AA	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Post Procedural Care Unit	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069AB	Child	DSH	WAKEMED	WakeMed Brier Creek Healthplex - Imaging Services - CT	8001 T. W. Alexander Dr.	Raleigh	NC	Active
DSH340069AC	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Imaging Services	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069AD	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Imaging Services Ultrasound	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069AE	Child	DSH	WAKEMED	WakeMed Raleigh Medical Park - Imaging Services	23 Sunnybrook Rd.	Raleigh	NC	Active
DSH340069AF	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Imaging Services MRI	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069AG	Child	DSH	WAKEMED	WakeMed Raleigh Medical Park - Imaging Services - MRI	23 Sunnybrook Rd.	Raleigh	NC	Active
DSH340069AH	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Imaging Services CT	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069AJ	Child	DSH	WAKEMED	WakeMed Raleigh Medical Park - Imaging Services - CT	23 Sunnybrook Rd.	Raleigh	NC	Active
DSH340069AM	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Emergency Department	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069AN	Child	DSH	WAKEMED	WakeMed Brier Creek Healthplex - Emergency Department	8001 T. W. Alexander Dr.	Raleigh	NC	Active
DSH340069AP	Child	DSH	WAKEMED	Mobile Ambulance Services	900 Management Way	Garner	NC	Active
DSH340069AQ	Child	DSH	WAKEMED	WakeMed Garner Healthplex- Emergency Department	400 US Highway 70 East	Garner	NC	Active
DSH340069AR	Child	DSH	WAKEMED	WakeMed Garner Healthplex-Imaging Services- Ultrasound	400 US Highway 70 East	Garner	NC	Active
DSH340069AS	Child	DSH	WAKEMED	WakeMed Garner Healthplex-Imaging Services- MRI	400 US Highway 70 East	Garner	NC	Active
DSH340069AT	Child	DSH	WAKEMED	WakeMed Garner Healthplex--Imaging Services-CT	400 US Highway 70 East	Garner	NC	Active
DSH340069AU	Child	DSH	WAKEMED	WakeMed Garner Healthplex--Imaging Services	400 US Highway 70 East	Garner	NC	Active
DSH340069AV	Child	DSH	WAKEMED	WakeMed Garner Healthplex - CV Testing EKG	400 US Highway 70 East	Garner	NC	Active
DSH340069AW	Child	DSH	WAKEMED	WakeMed Raleigh Medical Park - Imaging Services - Ultrasound	23 Sunnybrook Road	Raleigh	NC	Active
DSH340069AX	Child	DSH	WAKEMED	WakeMed Raleigh Medical Park - CV Testing - EKG	23 Sunnybrook Road	Raleigh	NC	Terminated
DSH340069AY	Child	DSH	WAKEMED	WakeMed Brier Creek Healthplex - CV Testing - EKG	8001 T.W. Alexander Dr.	Raleigh	NC	Active
DSH340069AZ	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - CV Testing - EKG	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069BA	Child	DSH	WAKEMED	WakeMed Brier Creek Healthplex - Imaging Services - Ultrasound	8001 T.W. Alexander Dr	Raleigh	NC	Active
DSH340069BC	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Labor and Delivery Triage/Post OP Observation	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069BD	Child	DSH	WAKEMED	WakeMed Physician Practices Special Infant Care - Special Infant Care	3024 New Bern Ave	Raleigh	NC	Active
DSH340069BE	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Labor & Delivery Postpartum - Labor & Delivery Postpartum	10000 Falls of Neuse Rd	Raleigh	NC	Active
DSH340069BF	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - OB/ED - OB/ED	10000 Falls of Neuse Rd	Raleigh	NC	Active
DSH340069BG	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Endoscopy - Endoscopy	10000 Falls of Neuse Rd	Raleigh	NC	Active
DSH340069BH	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - CV Testing - Cardiographic Lab - CV Testing - Cardiographic Lab	10000 Falls of Neuse Rd	Raleigh	NC	Active
DSH340069BJ	Child	DSH	WAKEMED	WakeMed North Family Health & Womens Hospital - Pain Management - Pain Management	10000 Falls of Neuse Rd	Raleigh	NC	Active
DSH340069BK	Child	DSH	WAKEMED	WakeMed Raleigh Medical Park - HOPD Hematology & Oncology - Oncology	23 Sunnybrook Rd	Raleigh	NC	Active
DSH340069BL	Child	DSH	WAKEMED	CENTER FOR COMMUNITY HEALTH - Community Health	2600 NEW BERN AVE	RALEIGH	NC	Active
DSH340069BM	Child	DSH	WAKEMED	WAKEMED CANCER CARE - WAVERLY HEMA - Oncology	210 ASHVILLE AVE	CARY	NC	Active
DSH340069BN	Child	DSH	WAKEMED	WAKEMED MEDICAL HEMATOLOGY AND ONCO - Oncology	10010 FALLS OF NEUSE RD	RALEIGH	NC	Active
DSH340069BP	Child	DSH	WAKEMED	WakeMed Raleigh Campus Atrial Fibrillation Center - Cardiology - Atrial Fibrillation	WakeMed	Raleigh	NC	Active
DSH340069BQ	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Nuclear Medicine - Nuclear Medicine	10000 Falls of Neuse Rd	Raleigh	NC	Active
DSH340069BR	Child	DSH	WAKEMED	WakeMed Wendell Healthplex - Imaging Services - CT Scan - Imaging Services - CT Scan	2021 Wendell Valley Blvd	Wendell	NC	Approved
DSH340069BS	Child	DSH	WAKEMED	WakeMed Wendell Healthplex - CV Testing - EKG - CV Testing - EKG	WakeMed Wendell Healthplex	Wendell	NC	Approved
DSH340069BT	Child	DSH	WAKEMED	WakeMed Wendell Healthplex - Emergency Department - Emergency Department	WakeMed Wendell Healthplex	Wendell	NC	Approved
DSH340069BU	Child	DSH	WAKEMED	WakeMed Wendell Healthplex - Imaging Services - Ultrasound - Imaging Services - Ultrasound	2021 Wendell Valley Blvd	Wendell	NC	Approved
DSH340069BV	Child	DSH	WAKEMED	WakeMed Wendell Healthplex - Imaging Services - Imaging Services	2021 Wendell Valley Blvd	Wendell	NC	Approved
DSH340069H	Child	DSH	WAKEMED	WakeMed Physician Practices Gastroenterology Raleigh	3024 New Bern Avenue	Raleigh	NC	Active
DSH340069M	Child	DSH	WAKEMED	WakeMed Physician Practices OB/Gyn Raleigh	3024 New Bern Avenue	Raleigh	NC	Active
DSH340069N	Child	DSH	WAKEMED	WakeMed Physician Practices Pediatrics	3024 New Bern Ave.	Raleigh	NC	Active
DSH340069T	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Surgical Services OR	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069W	Child	DSH	WAKEMED	WakeMed North Family Health & Women's Hospital - Anesthesiology	10000 Falls of Neuse Road	Raleigh	NC	Active
DSH340069X	Child	DSH	WAKEMED	WakeMed Brier Creek Healthplex - Imaging Services	8001 T. W. Alexander Dr.	Raleigh	NC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		GINTZIG, DONALD President and CEO Wakemed 9193508102	5/3/2025 5:32 AM
Details	340B ID	Update	New Registration		DSH340069BR	5/3/2025 5:32 AM
Details	Entity Subname	Update	New Registration	WakeMed Wendell Healthplex - Imaging Services - CT Scan	WakeMed Wendell Healthplex - Imaging Services - CT Scan - Imaging Services - CT Scan	5/3/2025 5:32 AM
Dates	Participating Approval Date	Update	New Registration		5/3/2025 5:32:53 AM	5/3/2025 5:32 AM
Details	State	Update	New Registration	Pending	Approved	5/3/2025 5:32 AM
Dates	Signed By Date	Update	New Registration		4/28/2025 3:35:57 PM	5/3/2025 5:32 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/3/2025 5:32 AM
Addresses	Main Address	Insert	New Registration		2021 Wendell Valley Blvd Wendell, NC 27591	4/8/2025 12:02 PM
Addresses	Billing Address	Insert	New Registration		WakeMed Wendell Healthplex Attn: Accounts Payable PO Box 14549 Raleigh, NC 27620	4/8/2025 12:02 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972579837	4/8/2025 12:02 PM
Medicaid Billing	NPI: State	Insert	New Registration		NC	4/8/2025 12:02 PM
Contacts	Primary Contact	Insert	New Registration		Williamson, Abbie Crisp Executive Director of Pharmacy Wakemed 9193508240	4/8/2025 12:02 PM
Contacts	Authorizing Official	Insert	New Registration		GINTZIG, DONALD President and CEO Wakemed 9193508102	4/8/2025 12:02 PM
Details	Assistance Received From Date	Insert	New Registration			4/8/2025 12:02 PM
Details	Assistance Received To Date	Insert	New Registration			4/8/2025 12:02 PM
Details	Last Recertification Date	Insert	New Registration			4/8/2025 12:02 PM
Details	Grant Number	Insert	New Registration			4/8/2025 12:02 PM
Details	340B ID	Insert	New Registration			4/8/2025 12:02 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/8/2025 12:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/8/2025 12:02 PM
Details	Medicare Provider Number	Insert	New Registration		340069	4/8/2025 12:02 PM
Details	Entity Name	Insert	New Registration		WAKEMED	4/8/2025 12:02 PM
Details	NOFO Number	Insert	New Registration			4/8/2025 12:02 PM
Details	Program Code	Insert	New Registration		DSH	4/8/2025 12:02 PM
Details	Entity Subname	Insert	New Registration		WakeMed Wendell Healthplex - Imaging Services - CT Scan	4/8/2025 12:02 PM
Dates	Participating Approval Date	Insert	New Registration			4/8/2025 12:02 PM
Details	State	Insert	New Registration		Pending	4/8/2025 12:02 PM
Dates	Registration Date	Insert	New Registration		4/8/2025 12:02:42 PM	4/8/2025 12:02 PM
Dates	Signed By Date	Insert	New Registration			4/8/2025 12:02 PM
Dates	Start Date	Insert	New Registration			4/8/2025 12:02 PM
Terminations	Termination Comments	Insert	New Registration			4/8/2025 12:02 PM
Terminations	Termination Date	Insert	New Registration			4/8/2025 12:02 PM
Terminations	Termination Effective Date	Insert	New Registration			4/8/2025 12:02 PM
Terminations	Termination Reason	Insert	New Registration			4/8/2025 12:02 PM