Covered Entity Details

DSH390002 UPMC MCKEESPORT (Active) - information as of 6/23/2025 11:56:21 PM

Main Details

Name

UPMC MCKEESPORT

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH390002

Medicare Provider Number

390002

Additional Details

Current Program Status

Active

Registration Date

8/28/2006

Participating Start Date

4/1/2012

Participating Approval Date

3/30/2012

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

UPMC McKeesport
Laurene Timmons, CFO
(412) 664-6781

Primary Contact

UPMC
Amanda Pell, Manager, 340B Program
(814) 771-8354

Addresses

Street Address

1500 FIFTH AVENUE
MCKEESPORT, PA 15132

Billing Address

UPMC Presbyterian Shadyside DBA UPMC Pharmacy Supply Chain
PO Box 2058
Portland, OR 97208

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
3/30/12 participating 10/1/06 thru 9/30/08, not participating 10/1/08 thru 3/31/12, removed ship to (was PROCUREMENT: H C PHARMACY CENTRAL, 3175 EAST CARSON STREET, PITTSBURGH, 15203), removed Medicaid # (1007643400014), added Medicaid # and NPI #;	03/30/2012

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	1007643400014	1992715510,1194734798,1659381275,1942364898,1043703531

Shipping Addresses

Shipping Address 1

UPMC MCKEESPORT OUTPATIENT PHARMACY
1500 5TH AVE
1 SHAW
McKeesport, PA 15132

Shipping Address 2

HC PHARMACY CENTRAL
3175 E CARSON ST
Pittsburgh, PA 15203

Shipping Address 3

UPMC MCKEESPORT HOSPITAL
1500 5TH AVE
MCKEESPORT, PA 15132

Shipping Address 4

UPMC Presbyterian Shadyside DBA Pharmacy Supply Chain
3175 E Carson St
Pittsburgh, PA 15203

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	07/17/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/17/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/17/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/17/2017	10/01/2017		10/01/2017
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CHARTWELL PENNSYLVANIA	1001 OAKDALE RD		OAKDALE	PA	15071-1502	10/29/2014	01/01/2015		10/29/2014
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	01/12/2024	04/01/2024		04/01/2024
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	01/12/2024	04/01/2024		04/01/2024
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/13/2021	10/01/2021		10/01/2021
Contract Detail	GIANT EAGLE PHARMACY #0015	ROUTE #30	1701 LINCOLN HIGHWAY	NORTH VERSAILLES	PA	15137	10/24/2013	01/01/2014	09/19/2016	10/05/2016
Contract Detail	GIANT EAGLE PHARMACY #0015	ROUTE #30	1701 LINCOLN HIGHWAY	NORTH VERSAILLES	PA	15137	07/10/2020	10/01/2020	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #0029	1356 HOFFMAN BLVD		WEST MIFFLIN	PA	15122	10/24/2013	01/01/2014	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #0060	4010 MONROEVILLE BLVD.		MONROEVILLE	PA	15146	07/10/2020	10/01/2020	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #0060	4010 MONROEVILLE BLVD.		MONROEVILLE	PA	15146	07/13/2021	10/01/2021		10/01/2021
Contract Detail	GIANT EAGLE PHARMACY #0064	3812 O'NEIL BLVD		MCKEESPORT	PA	15132	10/24/2013	01/01/2014	09/19/2016	10/05/2016
Contract Detail	GIANT EAGLE PHARMACY #0064	3812 O'NEIL BLVD		MCKEESPORT	PA	15132	07/10/2020	10/01/2020	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #0073	9901 MOUNTAINVIEW DRIVE		WEST MIFFLIN	PA	15122	07/10/2020	10/01/2020	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #0077	254 YOST BOULEVARD		PITTSBURGH	PA	15221	10/24/2013	01/01/2014	09/19/2016	10/05/2016
Contract Detail	GIANT EAGLE PHARMACY #0077	254 YOST BOULEVARD		PITTSBURGH	PA	15221	07/10/2020	10/01/2020	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #0221	20160 CENTER RIDGE ROAD, SUITE 201		ROCKY RIVER	OH	44116	07/13/2021	10/01/2021		10/01/2021
Contract Detail	GIANT EAGLE PHARMACY #1220	2001 LINCOLN WAY		WHITE OAK	PA	15131	10/24/2013	01/01/2014	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #1220	2001 LINCOLN WAY		WHITE OAK	PA	15131	07/13/2021	10/01/2021		10/01/2021
Contract Detail	GIANT EAGLE PHARMACY #1614	800 MCKEESPORT ROAD		ELIZABETH	PA	15037	10/24/2013	01/01/2014	09/19/2016	10/05/2016
Contract Detail	GIANT EAGLE PHARMACY #1619	EDGEWOOD TOWNE CENTER	1705 SOUTH BRADDOCK AVE	PITTSBURGH	PA	15218	10/24/2013	01/01/2014	09/19/2016	10/05/2016
Contract Detail	GIANT EAGLE PHARMACY #1619	EDGEWOOD TOWNE CENTER	1705 SOUTH BRADDOCK AVE	PITTSBURGH	PA	15218	07/10/2020	10/01/2020	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #6379	420 EAST WATERFRONT DRIVE		HOMESTEAD	PA	15120	07/10/2020	10/01/2020	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #6379	420 EAST WATERFRONT DRIVE		HOMESTEAD	PA	15120	07/13/2021	10/01/2021		10/01/2021
Contract Detail	GIANT EAGLE PHARMACY #8991	2500 LOVI RD		FREEDOM	PA	15042	07/10/2020	10/01/2020	04/09/2021	04/09/2021
Contract Detail	GIANT EAGLE PHARMACY #8991	2500 LOVI RD		FREEDOM	PA	15042	07/13/2021	10/01/2021		10/01/2021
Contract Detail	ONCOMED PHARMACEUTICAL SERVICES OF MA, L	D/B/A ONCO360	335 BEAR HILL RD STE 2100	WALTHAM	MA	02451	04/14/2022	07/01/2022		07/01/2022
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	10/11/2021	01/01/2022	04/07/2022	04/14/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/13/2021	10/01/2021		10/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/13/2021	10/01/2021		10/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/13/2021	10/01/2021		10/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	01/12/2024	04/01/2024		04/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #48611	141 PREBLE STREET	PORTLAND	ME	04101	01/12/2024	04/01/2024		04/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	CVS/PHARMACY #48637	2700 NORTHEAST EXPY NE STE B800 BUILDING B	ATLANTA	GA	30345	01/12/2024	04/01/2024		04/01/2024
Contract Detail	Rite Aid 6811	701 Delran Pkwy		Delran	NJ	08075	04/09/2025	07/01/2025	06/15/2025	05/14/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #2482	300 MARKET STREET	ELIZABETH	PA	15037	07/12/2023	10/01/2023	06/15/2025	06/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #7843	3700 WALNUT STREET	MCKEESPORT	PA	15132	07/12/2023	10/01/2023	06/15/2025	06/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #4682	600 WILLIAM MARKS DR	MUNHALL	PA	15120	07/12/2023	10/01/2023	06/15/2025	06/15/2025
Contract Detail	RITE AID OF PENNSYLVANIA, LLC	RITE AID #7924	2270 NOBLESTOWN ROAD	PITTSBURGH	PA	15205	07/12/2023	10/01/2023	06/15/2025	06/15/2025
Contract Detail	RX PARTNERS-LTC	500 OLD POND RD STE 406		BRIDGEVILLE	PA	15017	01/15/2020	04/01/2020	04/09/2021	04/09/2021
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	10/11/2021	01/01/2022		01/01/2022
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	04/14/2022	07/01/2022		07/01/2022
Contract Detail	THRIFT DRUG, INC.	RITE AID #10910	4927 HOMEVILLE ROAD	WEST MIFFLIN	PA	15122	07/12/2023	10/01/2023	06/15/2025	06/15/2025
Contract Detail	THRIFT DRUG, INC.	RITE AID #10969	10 CLAY PIKE	NORTH HUNTINGDON	PA	15642	07/12/2023	10/01/2023	06/15/2025	06/15/2025
Contract Detail	UPMC MCKEESPORT OUTPATIENT PHARMACY	1500 5TH AVE	1 SHAW	MCKEESPORT	PA	15132-2422	04/15/2013	07/01/2013	07/01/2023	07/12/2023
Contract Detail	UPMC MCKEESPORT OUTPATIENT PHARMACY	1500 5TH AVE	1 SHAW	MCKEESPORT	PA	15132-2422	07/02/2024	10/01/2024		10/01/2024
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-2019	355 WAL-MART DR		UNIONTOWN	PA	15401	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-2281	2351 CENTURY DR		WEST MIFFLIN	PA	15122	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-2588	100 WAL-MART DRIVE		NORTH VERSAILLES	PA	15137	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-2611	2100 SUMMIT RIDGE PLAZA		MT PLEASANT	PA	15666	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-3228	6700 HOLLYWOOD BLVD		DELMONT	PA	15626	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-3738	100 HIGHLANDS MALL		NATRONA HEIGHTS	PA	15065	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-5241	915 MILLS DRIVE		IRWIN	PA	15642	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-5379	1450 MORRELL AVENUE		CONNELLSVILLE	PA	15425	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/12/2023	10/01/2023		10/01/2023
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/12/2023	10/01/2023		10/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/11/2023	01/01/2024		01/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH390002A	Child	DSH	UPMC MCKEESPORT	UPMC MCKEESPORT - UNIONTOWN	103 Transit Drive	Uniontown	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Group Change Request		UPMC Presbyterian Shadyside DBA Pharmacy Supply Chain 3175 E Carson St Pittsburgh, PA 15203	5/14/2025 3:14 PM
Addresses	Billing Address	Update	Group Change Request	HC Pharmacy Central – Procurement 3175 East Carson Street Pittsburgh, PA 15203	UPMC Presbyterian Shadyside DBA UPMC Pharmacy Supply Chain PO Box 2058 Portland, OR 97208	5/14/2025 3:14 PM
Contacts	Primary Contact	Update	Group Change Request	Bedell, Stephen 340B Manager UPMC 7032325693	Pell, Amanda Manager, 340B Program UPMC 8147718354	10/15/2024 8:33 PM
Details	Last Recertification Date	Update	Recertification	8/25/2023 9:50:07 AM	8/28/2024 12:05:13 PM	8/28/2024 12:05 PM
Contacts	Primary Contact	Update	Group Change Request	Schonder, Matt M Director of Pharmacy UPMC McKeesport 4123573463	Bedell, Stephen 340B Manager UPMC 7032325693	3/22/2024 1:16 PM
Addresses	Shipping Address	Update	Change Request	UPMC McKeesport Outpatient Pharmacy 1500 Fifth Avenue, 1 Shaw McKeesport, PA 15132	UPMC MCKEESPORT OUTPATIENT PHARMACY 1500 5TH AVE 1 SHAW McKeesport, PA 15132	2/14/2024 8:12 AM
Addresses	Shipping Address	Update	Change Request	HC Pharmacy Central – Procurement 3175 East Carson Street Pittsburgh, PA 15203	HC PHARMACY CENTRAL 3175 E CARSON ST Pittsburgh, PA 15203	2/14/2024 8:12 AM
Addresses	Shipping Address	Insert	Change Request		UPMC MCKEESPORT HOSPITAL 1500 5TH AVE MCKEESPORT, PA 15132	2/14/2024 8:12 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 6:52:37 PM	8/25/2023 9:50:07 AM	8/25/2023 9:50 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 3:09:00 PM	8/29/2022 6:52:37 PM	8/29/2022 6:52 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	5784263 (OH)		8/23/2022 1:20 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0101249 (WV)		8/23/2022 1:20 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	01073330 (NY)		8/23/2022 1:20 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	4196007 (NJ)		8/23/2022 1:20 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1043703531	8/23/2022 1:20 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/23/2022 1:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1007643400014	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		5784263	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		OH	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		0101249	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		01073330	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NY	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		4196007	8/22/2022 11:16 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NJ	8/22/2022 11:16 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1992715510	8/22/2022 11:16 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/22/2022 11:16 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1194734798	8/22/2022 11:16 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/22/2022 11:16 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1659381275	8/22/2022 11:16 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/22/2022 11:16 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1942364898	8/22/2022 11:16 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	8/22/2022 11:16 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 4:03:25 PM	9/9/2021 3:09:00 PM	9/9/2021 3:09 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007643400037 (PA)		11/24/2020 1:27 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007643400035 (PA)		11/24/2020 1:27 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007643400014 (PA)		11/24/2020 1:27 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007643400023 (PA)		11/24/2020 1:27 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007643400001 (PA)		11/24/2020 1:27 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1659381275 (PA)		11/24/2020 1:27 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1992715510 (PA)		11/24/2020 1:27 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1942364898 (PA)		11/24/2020 1:27 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1194734798 (PA)		11/24/2020 1:27 PM
Medicaid Billing	NPI: State	Update	Recertification		PA	9/8/2020 4:03 PM
Medicaid Billing	NPI: State	Update	Recertification		PA	9/8/2020 4:03 PM
Medicaid Billing	NPI: State	Update	Recertification		PA	9/8/2020 4:03 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1396188777 ( )		9/8/2020 4:03 PM
Medicaid Billing	NPI: State	Update	Recertification		PA	9/8/2020 4:03 PM
Details	Last Recertification Date	Update	Recertification	9/9/2019 8:29:05 AM	9/8/2020 4:03:25 PM	9/8/2020 4:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/10/2020 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007643400037	7/10/2020 1:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	7/10/2020 1:32 PM
Contacts	Primary Contact	Update	Change Request	Wilson, Gregory L Director, Pharmacy UPMC 4128640720	Schonder, Matt M Director of Pharmacy UPMC McKeesport 4123573463	3/20/2020 11:43 AM
Addresses	Shipping Address	Insert	Recertification		HC Pharmacy Central – Procurement 3175 East Carson Street Pittsburgh, PA 15203	9/9/2019 8:29 AM
Addresses	Billing Address	Update	Recertification	HC Pharmacy – Procurement 3175 East Carson Street Pittsburgh, PA 15203	HC Pharmacy Central – Procurement 3175 East Carson Street Pittsburgh, PA 15203	9/9/2019 8:29 AM
Addresses	Shipping Address	Delete	Recertification	HC Pharmacy – Procurement 3175 East Carson Street Pittsburgh, PA 15203		9/9/2019 8:29 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1114937737 ( )		9/9/2019 8:29 AM
Details	Last Recertification Date	Update	Recertification	8/30/2018 1:48:13 PM	9/9/2019 8:29:05 AM	9/9/2019 8:29 AM
Contacts	Primary Contact	Update	Change Request	NICCOLAI, WILLIAM R. DIRECTOR OF PHARMACY UPMC McKeesport 4126642318	Wilson, Gregory L Director, Pharmacy UPMC 4128640720	4/5/2019 8:30 AM
Contacts	Signed By	Update		Stockhausen, Christopher CFO 4126642528	Stockhausen, Christopher CFO UPMC 4126642528	11/19/2018 1:23 PM
Details	Last Recertification Date	Update	Recertification	12/6/2017 9:12:16 AM	8/30/2018 1:48:13 PM	8/30/2018 1:48 PM
Addresses	Shipping Address	Insert	Recertification		UPMC McKeesport Outpatient Pharmacy 1500 Fifth Avenue, 1 Shaw McKeesport, PA 15132	12/6/2017 9:12 AM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	12/6/2017 9:12:16 AM	12/6/2017 9:12 AM
Contacts	Authorizing Official	Update		Timmons, Laurene CFO 4126646781	Timmons, Laurene CFO UPMC McKeesport 4126646781	10/2/2017 11:30 AM
Contacts	Primary Contact	Update		NICCOLAI, WILLIAM R. DIRECTOR OF PHARMACY 4126642318	NICCOLAI, WILLIAM R. DIRECTOR OF PHARMACY UPMC McKeesport 4126642318	9/29/2017 11:33 AM
Contacts	Authorizing Official	Update		MAMMARELLA, SUSAN CFO 4126642528	Timmons, Laurene CFO 4126646781	7/17/2017 4:23 PM
Contacts	Signed By	Insert			Stockhausen, Christopher CFO 4126642528	6/21/2017 7:15 AM
Addresses	Main Address	Insert			1500 FIFTH AVENUE MCKEESPORT, PA 15132	1/17/2017 8:07 AM
Addresses	Billing Address	Insert			HC Pharmacy – Procurement 3175 East Carson Street Pittsburgh, PA 15203	1/17/2017 8:07 AM
Addresses	Shipping Address	Insert			HC Pharmacy – Procurement 3175 East Carson Street Pittsburgh, PA 15203	1/17/2017 8:07 AM
Contacts	Primary Contact	Insert			NICCOLAI, WILLIAM R. DIRECTOR OF PHARMACY 4126642318	1/17/2017 8:07 AM
Details	Last Recertification Date	Update		8/11/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 8:58 AM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	8/11/2015 12:00:00 AM	8/11/2015 11:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: Number	Insert			1007643400014	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: State	Insert			PA	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: Number	Insert			1007643400023	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: State	Insert			PA	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: Number	Insert			1007643400001	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: State	Insert			PA	7/28/2015 9:27 AM
Medicaid Billing	NPI: Number	Insert			1114937737	7/28/2015 9:27 AM
Medicaid Billing	NPI: Number	Insert			1659381275	7/28/2015 9:27 AM
Medicaid Billing	NPI: Number	Insert			1992715510	7/28/2015 9:27 AM
Medicaid Billing	NPI: Number	Insert			1942364898	7/28/2015 9:27 AM
Medicaid Billing	NPI: Number	Insert			1396188777	7/28/2015 9:27 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/3/2014 1:46 PM
Medicaid Billing	Medicaid: Number	Insert			1007643400035	9/3/2014 1:46 PM
Medicaid Billing	Medicaid: State	Insert			PA	9/3/2014 1:46 PM
Details	Last Recertification Date	Update		9/6/2013 12:00:00 AM	9/3/2014 12:00:00 AM	9/3/2014 1:46 PM
Details	Last Recertification Date	Update			9/6/2013 12:00:00 AM	9/6/2013 8:12 AM
Dates	Participating Approval Date	Update			3/30/2012 12:00:00 AM	3/30/2012 4:58 PM
Details	State	Update		Terminated	Active	3/30/2012 4:58 PM
Terminations	Termination Date	Update		10/1/2008 12:00:00 AM		3/30/2012 4:58 PM
Terminations	Termination Reason	Update		DSH percentage below statutory minimum		3/30/2012 4:58 PM
Dates	Participating Approval Date	Update		8/28/2006 12:00:00 AM		3/30/2012 4:28 PM
Dates	Signed By Date	Update		8/17/2006 12:00:00 AM	12/12/2011 12:00:00 AM	3/30/2012 4:28 PM
Medicaid Billing	NPI: Number	Insert			1194734798	3/30/2012 2:43 PM
Dates	Start Date	Update		10/1/2006 12:00:00 AM	4/1/2012 12:00:00 AM	3/30/2012 2:43 PM
Details	Comments Public	Insert			3/30/12 participating 10/1/06 thru 9/30/08, not participating 10/1/08 thru 3/31/12, removed ship to (was PROCUREMENT: H C PHARMACY CENTRAL, 3175 EAST CARSON STREET, PITTSBURGH, 15203), removed Medicaid # (1007643400014), added Medicaid # and NPI #;	3/30/2012 2:43 PM
Contacts	Authorizing Official	Insert			MAMMARELLA, SUSAN CFO 4126642528	9/30/2008 10:07 AM
Details	Last Recertification Date	Insert				9/30/2008 10:07 AM
Details	Grant Number	Insert				9/30/2008 10:07 AM
Details	340B ID	Insert			DSH390002	9/30/2008 10:07 AM
Details	Is Authorizing Official EHB Data	Insert				9/30/2008 10:07 AM
Dates	Last Date That 340B Drugs Purchased	Insert				9/30/2008 10:07 AM
Details	Medicare Provider Number	Insert			390002	9/30/2008 10:07 AM
Details	Entity Name	Insert			UPMC MCKEESPORT	9/30/2008 10:07 AM
Details	Program Code	Insert			DSH	9/30/2008 10:07 AM
Details	Entity Subname	Insert				9/30/2008 10:07 AM
Dates	Participating Approval Date	Insert			8/28/2006 12:00:00 AM	9/30/2008 10:07 AM
Details	State	Insert			Terminated	9/30/2008 10:07 AM
Dates	Registration Date	Insert			8/28/2006 12:00:00 AM	9/30/2008 10:07 AM
Dates	Signed By Date	Insert			8/17/2006 12:00:00 AM	9/30/2008 10:07 AM
Dates	Start Date	Insert			10/1/2006 12:00:00 AM	9/30/2008 10:07 AM
Terminations	Termination Comments	Insert				9/30/2008 10:07 AM
Terminations	Termination Date	Insert			10/1/2008 12:00:00 AM	9/30/2008 10:07 AM
Terminations	Termination Effective Date	Insert				9/30/2008 10:07 AM
Terminations	Termination Reason	Insert			DSH percentage below statutory minimum	9/30/2008 10:07 AM