Covered Entity Details

DSH390113AB Meadville Medical Center (Approved) - information as of 5/20/2025 11:40:30 PM

Main Details

Name

Meadville Medical Center

Subdivision Name

OP Drug and Alcohol - Outpatient Stepping Stones

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH390113AB

Medicare Provider Number

390113

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/11/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/5/2025

Last Recertification Date

Contacts

Authorizing Official

Meadville Medical Center
Ellie Jo Amory, 340B Program Administrator
(814) 333-5669

Primary Contact

Meadville Medical Center
Sandra J. Clark, 340B Coordinator
(814) 373-2244

Addresses

Street Address

1034 Grove Street
Meadville, PA 16335-2945

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
PA	1007521150021,1007521150043,1007521150047,1007521150053,1007521150067,1007521150077,1007521150078,1007521150079,1007521150080,1007521150081,1007521150082,1007521150083,1007521150084,1007521150085,1007521150097,1007521150098,1007521150099,1007521150107,1007521150108,1007521150111,1007521150115,1007521150117,1007521150118,1007521150120,1007521150121,1007521150122,1007521150123,1007521150124,1007521150125,1007521150126,1007521150128,1007521150129,1007521150130,1007521150131,1007521150132,1007521150133,1007521150134,1007521150135,1007521150138,1007521150140,1007521150141,1007521150142,1007521150143,1007521150144	1124083928,1174067458,1174371280,1184791022,1235848987,1245089325,1255180329,1295084044,1295097863,1295145787,1326139775,1356495477,1366596488,1396480372,1417640079,1497017065,1538420658,1609077213,1629633573,1649026162,1659780039,1710031836,1841782869,1881008142,1942276423,1992859011

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
DSH390113A	Child	DSH	Meadville Medical Center	Mind Body Wellness Center	18201 Conneaut Lake Rd.	Meadville	PA	Active
DSH390113AA	Child	DSH	Meadville Medical Center	MEADVILLE UROLOGY - Urology Clinic	765 LIBERTY ST	MEADVILLE	PA	Active
DSH390113AB	Child	DSH	Meadville Medical Center	OP Drug and Alcohol - Outpatient Stepping Stones	1034 Grove Street	Meadville	PA	Approved
DSH390113B	Child	DSH	Meadville Medical Center	Meadville Pain Management	1015 Grove St.	Meadville	PA	Active
DSH390113C	Child	DSH	Meadville Medical Center	Yolanda G. Barco Oncology Institute	16792 Conneaut Lake Road	Meadville	PA	Active
DSH390113D	Child	DSH	Meadville Medical Center	Grove Street Surgery -OR	1034 Grove St	MEADVILLE	PA	Active
DSH390113E	Child	DSH	Meadville Medical Center	Center for Hypertension and Nephrology Care	765 Liberty St	MEADVILLE	PA	Active
DSH390113F	Child	DSH	Meadville Medical Center	NEUROLOGY CENTER OF MEADVILLE / Neurology	765 LIBERTY ST	MEADVILLE	PA	Active
DSH390113G	Child	DSH	Meadville Medical Center	MEADVILLE WORKPLACE HEALTH	11277 Vernon Place,	MEADVILLE	PA	Active
DSH390113H	Child	DSH	Meadville Medical Center	Clinic for Specialty Pain Services	1034 GROVE STREET	MEADVILLE	PA	Active
DSH390113J	Child	DSH	Meadville Medical Center	Meadville Dermatology & Skin Surgery Institute	149 N. Main St.	MEADVILLE	PA	Active
DSH390113K	Child	DSH	Meadville Medical Center	MEADVILLE MEDICAL CENTER / CT Scan-Vernon	11277 VERNON PLACE ROAD	MEADVILLE	PA	Active
DSH390113L	Child	DSH	Meadville Medical Center	MEADVILLE COMMUNITY HEALTH CENTER	640 Alden Street	MEADVILLE	PA	Terminated
DSH390113M	Child	DSH	Meadville Medical Center	CONNEAUT LAKE HEALTH CENTER	10926 HIGHWAY 18	CONNEAUT LAKE	PA	Terminated
DSH390113N	Child	DSH	Meadville Medical Center	CAMBRIDGE SPRINGS HEALTH CENTER	118 RAILROAD STREET	CAMBRIDGE SPRINGS	PA	Terminated
DSH390113P	Child	DSH	Meadville Medical Center	CONNEAUT VALLEY HEALTH CENTER	906 WASHINGTON STREET	CONNEAUTVILLE	PA	Terminated
DSH390113Q	Child	DSH	Meadville Medical Center	MEADVILLE MEDICAL CENTER / Mammography - Vernon	11277 VERNON PLACE ROAD	MEADVILLE	PA	Active
DSH390113R	Child	DSH	Meadville Medical Center	MEADVILLE MEDICAL CENTER / Ultrasound - Vernon	11277 VERNON PLACE ROAD	MEADVILLE	PA	Active
DSH390113S	Child	DSH	Meadville Medical Center	MEADVILLE MEDICAL CENTER / Radiology - Vernon	11277 VERNON PLACE ROAD	MEADVILLE	PA	Active
DSH390113T	Child	DSH	Meadville Medical Center	Meadville Medical Center/Vernon - MRI	11277 Vernon Place Road	Meadville	PA	Active
DSH390113U	Child	DSH	Meadville Medical Center	Yolanda G Barco Oncology Ins - Radiation Oncology - Radiation Oncology	16792 Conneaut Lake Rd	Meadville	PA	Active
DSH390113V	Child	DSH	Meadville Medical Center	MEADVILLE MEDICAL CENTER - GI Lab	1034 Grove St	Meadville	PA	Active
DSH390113W	Child	DSH	Meadville Medical Center	Meadville OBGYN Associates - Obstetrics and Gynecology	765 Liberty Street	Meadville	PA	Active
DSH390113X	Child	DSH	Meadville Medical Center	Meadville Gastroenterology - Gastroenterology	1034 Grove Street	Meadville	PA	Active
DSH390113Y	Child	DSH	Meadville Medical Center	MMC ENT - ENT	11277 VERNON PL	MEADVILLE	PA	Active
DSH390113Z	Child	DSH	Meadville Medical Center	PULMONARY ASSOCIATES OF MEADVILLE - Pulmonology	765 LIBERTY ST	MEADVILLE	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Amory, Ellie Jo 340B Program Administrator Meadville Medical Center 8143335669	5/5/2025 7:46 AM
Details	340B ID	Update	New Registration		DSH390113AB	5/5/2025 7:46 AM
Details	Entity Name	Update	New Registration	MEADVILLE MEDICAL CENTER	Meadville Medical Center	5/5/2025 7:46 AM
Details	Entity Subname	Update	New Registration	OP Drug and Alcohol	OP Drug and Alcohol - Outpatient Stepping Stones	5/5/2025 7:46 AM
Dates	Participating Approval Date	Update	New Registration		5/5/2025 7:46:57 AM	5/5/2025 7:46 AM
Details	State	Update	New Registration	Pending	Approved	5/5/2025 7:46 AM
Dates	Signed By Date	Update	New Registration		4/14/2025 8:20:31 AM	5/5/2025 7:46 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/5/2025 7:46 AM
Addresses	Main Address	Insert	New Registration		1034 Grove Street Meadville, PA 16335-2945	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150021	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150043	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150047	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150053	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150067	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150077	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150078	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150079	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150080	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150081	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150082	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150083	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150084	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150085	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150097	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150098	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150099	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150107	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150108	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150111	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150115	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150117	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150118	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150120	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150121	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150122	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150123	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150124	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150125	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150126	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150128	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150129	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150130	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150131	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150132	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150133	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150134	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150135	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150138	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150140	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150141	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150142	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150143	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007521150144	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1124083928	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174067458	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1174371280	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1184791022	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1235848987	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1245089325	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1255180329	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295084044	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295097863	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1295145787	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1326139775	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1356495477	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366596488	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1396480372	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1417640079	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1497017065	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1538420658	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1609077213	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1629633573	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1649026162	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1659780039	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1710031836	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1841782869	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1881008142	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1942276423	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1992859011	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/11/2025 11:06 AM
Contacts	Primary Contact	Insert	New Registration		Clark, Sandra J. 340B Coordinator Meadville Medical Center 8143732244	4/11/2025 11:06 AM
Contacts	Authorizing Official	Insert	New Registration		Amory, Ellie Jo 340B Program Administrator Meadville Medical Center 8143335669	4/11/2025 11:06 AM
Details	Assistance Received From Date	Insert	New Registration			4/11/2025 11:06 AM
Details	Assistance Received To Date	Insert	New Registration			4/11/2025 11:06 AM
Details	Last Recertification Date	Insert	New Registration			4/11/2025 11:06 AM
Details	Grant Number	Insert	New Registration			4/11/2025 11:06 AM
Details	340B ID	Insert	New Registration			4/11/2025 11:06 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2025 11:06 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2025 11:06 AM
Details	Medicare Provider Number	Insert	New Registration		390113	4/11/2025 11:06 AM
Details	Entity Name	Insert	New Registration		MEADVILLE MEDICAL CENTER	4/11/2025 11:06 AM
Details	NOFO Number	Insert	New Registration			4/11/2025 11:06 AM
Details	Program Code	Insert	New Registration		DSH	4/11/2025 11:06 AM
Details	Entity Subname	Insert	New Registration		OP Drug and Alcohol	4/11/2025 11:06 AM
Dates	Participating Approval Date	Insert	New Registration			4/11/2025 11:06 AM
Details	State	Insert	New Registration		Pending	4/11/2025 11:06 AM
Dates	Registration Date	Insert	New Registration		4/11/2025 11:06:08 AM	4/11/2025 11:06 AM
Dates	Signed By Date	Insert	New Registration			4/11/2025 11:06 AM
Dates	Start Date	Insert	New Registration			4/11/2025 11:06 AM
Terminations	Termination Comments	Insert	New Registration			4/11/2025 11:06 AM
Terminations	Termination Date	Insert	New Registration			4/11/2025 11:06 AM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2025 11:06 AM
Terminations	Termination Reason	Insert	New Registration			4/11/2025 11:06 AM