Covered Entity Details

DSH340014 Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center (Terminated) - information as of 4/25/2025 12:01:01 AM

Main Details

Name

Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340014

Medicare Provider Number

340014

Additional Details

Current Program Status

Terminated

Registration Date

6/6/2007

Participating Start Date

7/1/2007

Participating Approval Date

6/11/2007

Last Recertification Date

9/6/2019

Termination Date
Termination Reason

7/7/2020
DSH percentage below statutory minimum

Contacts

Authorizing Official

Novant Health
Geoffrey Gardner, SVP Finance
(336) 718-2078

Primary Contact

Novant Health
Elizabeth Anne Corazzo, Manager Pharmacy 340B
(336) 277-0301

Addresses

Street Address

3333 SILAS CREEK PARKWAY
WINSTON-SALEM, NC 27103-3013

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Forsyth Memorial Hospital transitioned from a DSH to an RRC on 7/7/2020	07/30/2020
4/29/08- ADDED MEDICAID # 3400014; 8/30/07- DOCUMENTATION SUBMITTED TO CONFIRM ELIGIBLE DSH ADJUSTMENT PERCENTAGE	04/29/2008

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
		1447200233,1114979663

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	FORSYTH MEMORIAL HOSPITAL	DBA NOVANT HEALTH PHARMACY	3333 SILAS CREEK PKWY	WINSTON SALEM	NC	27103-3013	10/28/2016	01/01/2017	07/07/2020	07/30/2020
Contract Detail	NOVANT HEALTH PHARMACY SERVICES LLC	DBA: NOVANT HEALTH PHARMACY	3333 SILAS CREEK PARKWAY RETAIL PHARMACY - MAIN FLOOR - LOBBY	WINSTON SALEM	NC	27103-3090	10/28/2016	01/01/2017	12/11/2019	12/12/2019
Contract Detail	NOVANT HEALTH PHARMACY SERVICES LLC	DBA: NOVANT HEALTH PHARMACY	291 BROAD ST	KERNERSVILLE	NC	27284-2932	10/28/2016	01/01/2017	10/31/2019	11/01/2019
Contract Detail	NOVANT HEALTH PHARMACY SERVICES LLC	DBA: NOVANT HEALTH PHARMACY	105 VEST MILL ROAD	WINSTON SALEM	NC	27103	10/28/2016	01/01/2017	10/31/2019	11/01/2019
Contract Detail	NOVANT HEALTH PHARMACY SERVICES LLC	DBA: NOVANT HEALTH PHARMACY	212 MOORE ROAD	KING	NC	27021-8703	10/28/2016	01/01/2017	12/11/2019	12/12/2019
Contract Detail	NOVANT HEALTH PHARMACY SERVICES LLC	DBA: NOVANT HEALTH PHARMACY	100 ROBINHOOD MEDICAL PLAZA	WINSTON SALEM	NC	27106	10/28/2016	01/01/2017	10/31/2019	11/01/2019
Contract Detail	NOVANT HEALTH PHARMACY SERVICES LLC	DBA NOVANT HEALTH PHARMACY	1381 WESTGATE CENTER DR	WINSTON SALEM	NC	27103-2934	10/28/2016	01/01/2017	10/31/2019	11/01/2019
Contract Detail	NOVANT HEALTH PHARMACY SERVICES LLC	DBA NOVANT HEALTH PHARMACY	255 CHARLOIS BLVD	WINSTON-SALEM	NC	27103	10/28/2016	01/01/2017	12/11/2019	12/12/2019
Contract Detail	NOVANT HEALTH THOMASVILLE MEDICAL CENTER	DBA NOVANT HEALTH SPECIALTY PHARMACY	1381 WESTGATE CENTER DR	WINSTON SALEM	NC	27103	10/28/2016	01/01/2017	07/07/2020	07/30/2020
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01253	340 N MAIN STREET	KERNERSVILLE	NC	27284-2881	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06690	3634 REYNOLDA ROAD	WINSTON SALEM	NC	27106-2230	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07280	1015 RANDOLPH STREET	THOMASVILLE	NC	27360-5726	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07397	2125 CLOVERDALE AVE	WINSTON SALEM	NC	27103-2506	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07647	3488 ROBIN HOOD ROAD	WINSTON SALEM	NC	27106-4702	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09191	4996 COUNTRY CLUB RD	WINSTON SALEM	NC	27104	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09558	2795 LEWISVILLE-CLEMMONS RD	CLEMMONS	NC	27012	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10086	2069 ROCKFORD ST.	MOUNT AIRY	NC	27030	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10089	1327 MEADOWLARK DR.	WINSTON SALEM	NC	27106	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10090	12311 N. NC HIGHWAY 150	WINSTON SALEM	NC	27127	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10566	901 YADKINVILLE RD	MOCKSVILLE	NC	27028-2033	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10674	5322 U.S. HIGHWAY 158	ADVANCE	NC	27006-6907	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11202	1712 S. STRATFORD RD.	WINSTON SALEM	NC	27103	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12437	1250 FAIRVIEW DR.	LEXINGTON	NC	27292	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12562	2912 MAIN ST.	WALKERTOWN	NC	27051	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15009	5496 UNIVERSITY PARKWAY	WINSTON SALEM	NC	27105-1366	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	WALGREENS #16112	722 W. INDEPENDENCE BLVD	MOUNT AIRY	NC	27030	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	WALGREENS #21285	212A MOORE RD	KING	NC	27021	12/20/2019	01/01/2020	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	WALGREENS #21283	3333 SILAS CREEK PKWY SUITE T10479	WINSTON SALEM	NC	27103	12/20/2019	01/01/2020	07/07/2020	07/30/2020
Contract Detail	WALGREEN CO.	WALGREENS #21282	255A CHARLOIS BLVD	WINSTON SALEM	NC	27103	12/20/2019	01/01/2020	07/07/2020	07/30/2020
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/11/2019	10/01/2019	07/07/2020	07/30/2020
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	07/11/2019	10/01/2019	07/07/2020	07/30/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH340014A	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Salem Family Medicine	105 VEST MILL CIRCLE	WINSTON-SALEM	NC	Terminated
DSH340014AA	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Family Medicine	291 Broad Street	Kernersville	NC	Terminated
DSH340014AB	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Northwest Family Medicine	7607-B Highway 68N	Oak Ridge	NC	Terminated
DSH340014AC	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Lexington Primary Care	110 West Medical Park Drive	Lexington	NC	Terminated
DSH340014AE	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Davie Medical Associates	485 Valley Road	Mocksville	NC	Terminated
DSH340014AF	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Hillsdale Medical Associates	121 Medical Drive	Advance	NC	Terminated
DSH340014AG	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Surry Medical Associates	865 Westlake Drive	Mount Airy	NC	Terminated
DSH340014AH	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Pilot Mountain Medical Care	207 Medical Street	Pilot Mountain	NC	Terminated
DSH340014AJ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health West Forsyth Internal Medicine and Pediatrics	105 Stadium Oaks Drive	Clemmons	NC	Terminated
DSH340014AK	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Yadkin Medical Associates	305 East Lee Avenue	Yadkinville	NC	Terminated
DSH340014AL	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health New Garden Medical Associates	1941 New Garden Road	Greensboro	NC	Terminated
DSH340014AM	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Wound Care and Hyperbaric Medicine	250 Charlois Boulevard	Winston-Salem	NC	Terminated
DSH340014AN	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Hawthorne Outpatient Surgery	1999 South Hawthorne Road	Winston-Salem	NC	Terminated
DSH340014AP	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Orthopedic Outpatient Surgery	180 Kimel Park Drive	Winston-Salem	NC	Terminated
DSH340014AQ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Maplewood Family Medicine	100 Robinhood Medical Plaza	Winston-Salem	NC	Terminated
DSH340014AR	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health North Point Medical Associates	1995 Bethabara Road	Winston-Salem	NC	Terminated
DSH340014AS	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Premier Medical Associates	3333 Brookview Hills Boulevard	Winston-Salem	NC	Terminated
DSH340014AT	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Thomasville Medical Associates	309 Pineywood Road	Thomasville	NC	Terminated
DSH340014AU	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Rheumatology and Arthritis	1551 Westbrook Plaza Dr	Winston-Salem	NC	Terminated
DSH340014AV	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Triad Endocrine	500 Pineview Drive	Kernersville	NC	Terminated
DSH340014AX	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Urology Partners - Baldwin	2010 Baldwin Lane	Winston-Salem	NC	Terminated
DSH340014AY	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Urology Partners - Kernersville	1730 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014AZ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Winston Salem Health Care (Dermatology)	175 Kimel Park Drive	Winston Salem	NC	Terminated
DSH340014B	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Mountainview Medical	212 MOORE ROAD	KING	NC	Terminated
DSH340014BB	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Forsyth Family Medicine	400 Jonestown Road	Winston-Salem	NC	Terminated
DSH340014BC	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Cardiology Kernersville	1710 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BD	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Cardiology Winston-Salem	186 Kimel Park Drive	Winston-Salem	NC	Terminated
DSH340014BE	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Speech therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BF	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Operating Room	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BG	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Recovery Room (PACU)	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BH	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Anesthesia	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BJ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Radiology	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BK	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Nuclear Medicine	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BL	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Radiology Ultrasound	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BM	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Radiology CT Scanners	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BN	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Laboratory	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BP	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Anatomic Pathology	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BQ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Cardio-Pulmonary Services	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BR	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Physical Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BS	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Occupational Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BT	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Neurodiagnostics	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BU	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Rehab Clinics	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BV	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Medical Surgical	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BW	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Bariatric Solutions	760 Highland Oaks Dr	Winston-Salem	NC	Terminated
DSH340014BX	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH ONCOLOGY SPECIALISTS	1010 BETHESDA COURT	WINSTON-SALEM	NC	Terminated
DSH340014BY	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center ICU	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014BZ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Mammography	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014C	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Winston-Salem Health Care	250 CHARLOIS BLVD.	WINSTON SALEM	NC	Terminated
DSH340014CA	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH KERNERSVILLE MEDICAL CLINICAL DECISION	1750 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014CB	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Clinical Laboratory	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014CC	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Osteoporosis Clinic - Kernersville	1710 Kernersville Medical Blvd	Kernersville	NC	Terminated
DSH340014CD	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Convenient Care Clinic	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CE	Child	DSH	FORSYTH MEMORIAL HOSPITAL INC	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Psychiatry	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CF	Child	DSH	FORSYTH MEMORIAL HOSPITAL INC	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Chemo Clinic	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CG	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Laboratory	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CH	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Internal Medicine	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CJ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	WINSTON-SALEM HEALTHCARE / Novant Health Winston Salem Health Care Coumadin Clinic	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014CK	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Pfafftown Family Medicine	4611 Yadkinville Road	Pfafftown	NC	Terminated
DSH340014CL	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH VILLAGE POINT FAMILY Medicine	7130 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CM	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Emergency Room Observation and Procedure	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CN	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Emergency Room	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CP	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Physical Therapy	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CQ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Respiratory	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CR	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Clinical Laboratory	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CS	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Cat Scan	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CT	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Ultrasound	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CU	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Radiology	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CV	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Recovery Room	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CW	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Operating Room	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CX	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT / CMC Anesthesia	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014CY	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CARDIOLOGY MT AIRY	694 RIVERSIDE DR	MOUNT AIRY	NC	Terminated
DSH340014CZ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CARDIOLOGY CLEMMONS	7114 VILLAGE MEDICAL CIR	CLEMMONS	NC	Terminated
DSH340014DA	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	FORSYTH MEMORIAL HOSPITAL INC / NH Cardiology WSHC	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
DSH340014DB	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT - Outpatient Infusion	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014DC	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NH SURRY MEDICAL ASSOCIATES (ROCKFORD)	2133 ROCKFORD STREET	MT AIRY	NC	Terminated
DSH340014DD	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH PSYCHIATRIC MEDICINE	309 PINEYWOOD ROAD	THOMASVILLE	NC	Terminated
DSH340014DE	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH RHEUMATOLOGY & ARTHRITIS - WESTBROOK	1551 WESTBROOK PLAZA DR	WINSTON SALEM	NC	Terminated
DSH340014DF	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Wound Care Hyperbaric Medicine - Hawthorne	1901 S Hawthorne Rd	Winston Salem	NC	Terminated
DSH340014DG	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center / KMC PAV - KMC Pre-Anesthesia Visit	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014DH	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Clemmons Medical Cent / CMC PAV - CMC Pre-Anesthesia Visit	6915 Village Medical Circle	Clemmons	NC	Terminated
DSH340014DJ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Clemmons Medical Center/ CMC Occupational Therapy	6915 Village Medical Circle	Clemmons	NC	Terminated
DSH340014DK	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center / KMC Mobile PET - KMC Mobile PET	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014DL	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Intermediate Unit (IMU)	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014DM	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Clemmons Medical Center / CMC Clinical Nursing (2A&2B) Observation	6915 Village Medical Circle	Clemmons	NC	Terminated
DSH340014DN	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT - Novant Health Clemmons Medical Center Speech Therapy	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014DP	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	FORSYTH MEMORIAL HOSPITAL IN - DBA Novant Health Psychiatry-Forsyth	175 KIMEL PARK DR	WINSTON SALEM	NC	Terminated
DSH340014DQ	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH UROLOGY - Novant Health Urology - Kimel Park	140 KIMEL PARK DR	WINSTON SALEM	NC	Terminated
DSH340014DR	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Osteoporosis Clinic - Winston Salem - Osteoporosis clinic	3333 Silas Creek Parkway	Winston-Salem	NC	Terminated
DSH340014DS	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH CLEMMONS MEDICAL CENT - Novant Health Clemmons Medical Center Cardiac Non-Invasive Lab	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Terminated
DSH340014DT	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH TRIAD ENDOCRINE - Endocrinology	1941 NEW GARDEN RD	GREENSBORO	NC	Terminated
DSH340014DU	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	FORSYTH MEMORIAL HOSPITAL INC - Novant Health Rheumatology & Arthritis - Kernersville	291 BROAD ST	KERNERSVILLE	NC	Terminated
DSH340014DV	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH FORSYTH ENDOCRINE CON - Novant Health Forsyth Endocrine - Thomasville	903 RANDOLPH ST	THOMASVILLE	NC	Terminated
DSH340014E	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Oncology Specialists	1710 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014F	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Oncology Specialists	1213 Lexington Avenue	Thomasville	NC	Terminated
DSH340014G	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Oncology Specialists	865 WEST LAKE DRIVE	MOUNT AIRY	NC	Terminated
DSH340014H	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Oncology Specialists	276 OLD MOCKSVILLE ROAD	STATESVILLE	NC	Terminated
DSH340014J	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health KERNERSVILLE MEDICAL CENTER CARDIAC NON-INVASIVE LAB	1750 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014K	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH KERNERSVILLE MEDICAL CENTER/KMC WOUND & HYPERBARIC	1750 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014L	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH OUTPATIENT WOUND CARE CENTER - KERNERSVILLE	1710 KERNERSVILLE MEDICAL PKWY	KERNERSVILLE	NC	Terminated
DSH340014M	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Kernersville Medical Center Emergency Department	1750 Kernersville Medical Parkway	Kernersville	NC	Terminated
DSH340014N	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	NOVANT HEALTH KERNERSVILLE MEDICAL CENTER OUTPATIENT INFUSION	1750 KERNERSVILLE MEDICAL PARKWAY	KERNERSVILLE	NC	Terminated
DSH340014P	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Arcadia Family Medicine	12208 N NC Highway 150	Winston-Salem	NC	Terminated
DSH340014Q	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Chair City Family Medicine	903 Randolph Street	Thomasville	NC	Terminated
DSH340014R	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Clemmons Family Medicine	6301 Stadium Drive	Clemmons	NC	Terminated
DSH340014S	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Lewisville Family Medicine	1225 Lewisville-Clemmons Road	Lewisville	NC	Terminated
DSH340014T	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Forsyth Neurology	2025 Frontis Plaza Boulevard	Winston-Salem	NC	Terminated
DSH340014U	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Forsyth Endocrine Consultants	755 Highland Oaks Drive	Winston-Salem	NC	Terminated
DSH340014W	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Forsyth Internal Medicine	1381 Westgate Center Drive	Winston-Salem	NC	Terminated
DSH340014Y	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Infectious Disease Specialists	1381 Westgate Center Drive	Winston-Salem	NC	Terminated
DSH340014Z	Child	DSH	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	Novant Health Gateway Family Medicine	390 Salem Avenue	Winston-Salem	NC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Hansen, Elizabeth Corazzo Supervisor Pharmacy 340B Novant Health 3362770301	Corazzo, Elizabeth Anne Manager Pharmacy 340B Novant Health 3362770301	2/7/2023 4:18 PM
Details	Comments Public	Insert	OPA Edit		Forsyth Memorial Hospital transitioned from a DSH to an RRC on 7/7/2020	7/30/2020 7:53 AM
Details	State	Update	OPA Edit Termination Info	To Be Terminated	Terminated	7/30/2020 7:52 AM
Terminations	Termination Date	Update	OPA Edit Termination Info	10/1/2020 12:00:00 AM	7/7/2020 12:00:00 AM	7/30/2020 7:52 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		7/1/2020 12:00:00 AM	7/6/2020 7:54 AM
Details	State	Update	Termination Request	Active	To Be Terminated	7/6/2020 7:54 AM
Terminations	Termination Date	Update	Termination Request		10/1/2020 12:00:00 AM	7/6/2020 7:54 AM
Terminations	Termination Effective Date	Update	Termination Request		7/2/2020 12:00:00 AM	7/6/2020 7:54 AM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	7/6/2020 7:54 AM
Contacts	Authorizing Official	Update	Change Request	Terrell, Cedric A SVP Pharmacy Services Novant Health, Inc. 7043840611	Gardner, Geoffrey SVP Finance Novant Health 3367182078	1/17/2020 8:23 AM
Details	Last Recertification Date	Update	Recertification	8/31/2018 11:50:11 AM	9/6/2019 11:48:02 AM	9/6/2019 11:48 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1006173 (AK)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	XHSP41220 (CA)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	008047573 (CT)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	03019630 (DC)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	096065900 (FL)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000105509A (GA)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1209647 (MA)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00-220614 (MS)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0146738 (OH)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000882126-000 (PA)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0-340014 (TN)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	009812521 (VA)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0174828000 (WV)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	80571600 (WI)		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3400014 (NC)		7/12/2019 10:40 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1902858459 ( )		7/12/2019 10:40 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1006173	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		XHSP41220	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		008047573	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		03019630	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DC	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		096065900	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000105509A	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1209647	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		00-220614	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0146738	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000882126-000	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0-340014	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		009812521	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0174828000	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		80571600	8/31/2018 11:50 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	8/31/2018 11:50 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 10:18:30 PM	8/31/2018 11:50:11 AM	8/31/2018 11:50 AM
Contacts	Authorizing Official	Update	Change Request	Smith, Harry Lloyd SVP Hospital Operations, Interim President & COO Novant Health, Inc., Novant Health Forsyth Medical Center 7043849646	Terrell, Cedric A SVP Pharmacy Services Novant Health, Inc. 7043840611	7/5/2018 7:25 AM
Contacts	Authorizing Official	Update	Change Request	Sanz, Sean M. SVP & COO NHFMC Novant Health Forsyth Medical Center 3367182029	Smith, Harry Lloyd SVP Hospital Operations, Interim President & COO Novant Health, Inc., Novant Health Forsyth Medical Center 7043849646	4/30/2018 2:54 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/15/2017 10:18:30 PM	11/15/2017 10:18 PM
Contacts	Authorizing Official	Update		Sanz, Sean M. SVP & COO NHFMC 3367182029	Sanz, Sean M. SVP & COO NHFMC Novant Health Forsyth Medical Center 3367182029	11/10/2017 11:11 AM
Contacts	Primary Contact	Update	Recertification	Hansen, Elizabeth Supervisor Pharmacy 340B Novant Health 3362770301	Hansen, Elizabeth Corazzo Supervisor Pharmacy 340B Novant Health 3362770301	11/6/2017 10:31 AM
Contacts	Primary Contact	Update		Hansen, Elizabeth Supervisor Pharmacy 340B 3362770301	Hansen, Elizabeth Supervisor Pharmacy 340B Novant Health 3362770301	9/27/2017 2:34 PM
Contacts	Authorizing Official	Update		ALLEN, JOANNE PRESIDENT 3365644850	Sanz, Sean M. SVP & COO NHFMC 3367182029	8/3/2017 3:00 PM
Contacts	Primary Contact	Update		Brown, Kathryn N. Director of Pharmacy 3367182134	Hansen, Elizabeth Supervisor Pharmacy 340B 3362770301	8/3/2017 3:00 PM
Addresses	Main Address	Insert			3333 SILAS CREEK PARKWAY WINSTON-SALEM, NC 27103-3013	8/3/2017 3:00 PM
Details	Last Recertification Date	Update		8/17/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 3:46 PM
Contacts	Primary Contact	Update		Brown, Kathryn N. Director of Pharmacy 3367182134	Brown, Kathryn N. Director of Pharmacy 3367182134	12/30/2015 11:35 AM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/17/2015 11:01 AM
Details	Last Recertification Date	Update		8/22/2014 12:00:00 AM	8/17/2015 12:00:00 AM	8/17/2015 11:01 AM
Medicaid Billing	NPI: Number	Insert			1902858459	7/30/2015 2:23 PM
Medicaid Billing	NPI: Number	Insert			1114979663	7/30/2015 2:23 PM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	8/22/2014 12:00:00 AM	8/22/2014 11:35 AM
Contacts	Primary Contact	Insert			Brown, Kathryn N. Director of Pharmacy 3367182134	7/30/2014 8:42 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 11:14 AM
Details	Entity Name	Update		Forsyth Memorial Hospital, Inc d/b/a Norvant Health Forsyth Medical Center	Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center	7/3/2013 12:21 PM
Details	Entity Name	Update		FORSYTH MEMORIAL HOSPITAL, INC.	Forsyth Memorial Hospital, Inc d/b/a Norvant Health Forsyth Medical Center	7/3/2013 9:34 AM
Medicaid Billing	NPI: Number	Insert			1447200233	3/14/2013 11:50 AM
Contacts	Authorizing Official	Update		Hammes, Paul H. Sr. Vice President and Chief Operating Officer 3367182089	ALLEN, JOANNE PRESIDENT 3365644850	11/29/2012 11:12 AM
Contacts	Authorizing Official	Insert			Hammes, Paul H. Sr. Vice President and Chief Operating Officer 3367182089	6/26/2012 2:23 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/29/2012 1:54 PM
Details	Last Recertification Date	Insert				4/29/2008 12:20 PM
Details	Grant Number	Insert				4/29/2008 12:20 PM
Details	340B ID	Insert			DSH340014	4/29/2008 12:20 PM
Details	Is Authorizing Official EHB Data	Insert				4/29/2008 12:20 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/29/2008 12:20 PM
Details	Medicare Provider Number	Insert			340014	4/29/2008 12:20 PM
Details	Entity Name	Insert			FORSYTH MEMORIAL HOSPITAL, INC.	4/29/2008 12:20 PM
Details	Program Code	Insert			DSH	4/29/2008 12:20 PM
Details	Entity Subname	Insert				4/29/2008 12:20 PM
Dates	Participating Approval Date	Insert			6/11/2007 12:00:00 AM	4/29/2008 12:20 PM
Details	State	Insert			Active	4/29/2008 12:20 PM
Dates	Registration Date	Insert			6/6/2007 12:00:00 AM	4/29/2008 12:20 PM
Dates	Signed By Date	Insert			5/20/2007 12:00:00 AM	4/29/2008 12:20 PM
Dates	Start Date	Insert			7/1/2007 12:00:00 AM	4/29/2008 12:20 PM
Terminations	Termination Comments	Insert				4/29/2008 12:20 PM
Terminations	Termination Date	Insert				4/29/2008 12:20 PM
Terminations	Termination Effective Date	Insert				4/29/2008 12:20 PM
Terminations	Termination Reason	Insert				4/29/2008 12:20 PM
Details	Comments Public	Insert			4/29/08- ADDED MEDICAID # 3400014; 8/30/07- DOCUMENTATION SUBMITTED TO CONFIRM ELIGIBLE DSH ADJUSTMENT PERCENTAGE	4/29/2008 12:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	6/6/2007 3:29 PM
Medicaid Billing	Medicaid: Number	Insert			3400014	6/6/2007 3:29 PM
Medicaid Billing	Medicaid: State	Insert			NC	6/6/2007 3:29 PM