Covered Entity Details

DSH340151 Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital (Active) - information as of 5/25/2025 1:18:31 AM

Main Details

Name

Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH340151

Medicare Provider Number

340151

Additional Details

Current Program Status

Active

Registration Date

4/23/2008

Participating Start Date

7/1/2004

Participating Approval Date

4/23/2008

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

ECU Health North Hospital
Ryan Todd Hickey, President
(252) 535-8159

Primary Contact

ECU Health North Hospital
Amy Bennett, Pharmacy Manager
(252) 535-8274

Addresses

Street Address

250 SMITH CHURCH ROAD
ROANOKE RAPIDS, NC 27870

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
FL	1346273943	1346273943
MD	1346273943	1346273943
NY	1346273943	1346273943
SC	1346273943	1346273943
VA	1346273943	1346273943
NJ	1346273943	1346273943
DC	1346273943	1346273943
PA	1346273943	1346273943
NC	1346273943	1346273943
KY	1346273943	1346273943
OH	1346273943	1346273943
MA	1346273943	1346273943
CA	1346273943	1346273943
TX	1346273943	1346273943
AZ	1346273943	1346273943
ID	1346273943	1346273943
TN	1346273943	1346273943
NM	1346273943	1346273943
UT	1346273943	1346273943
MN	1346273943	1346273943
MO	1346273943	1346273943
GA	1346273943	1346273943
LA	1346273943	1346273943
IN	1346273943	1346273943

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	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	10/13/2023	01/01/2024		01/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	10/13/2023	01/01/2024		01/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	10/13/2023	01/01/2024		01/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/13/2023	01/01/2024		01/01/2024
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/13/2023	01/01/2024		01/01/2024
Contract Detail	DDP PHARMACY	DBA DRUGCO DISCOUNT PHARMACY	107 SMITH CHURCH RD	ROANOKE RAPIDS	NC	27870	01/16/2024	04/01/2024		04/01/2024
Contract Detail	DDP PHARMACY, INC.	DBA DRUGCO EXPRESS	1096 E 10TH ST	ROANOKE RAPIDS	NC	27870-3052	01/16/2024	04/01/2024		04/01/2024
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	10/13/2023	01/01/2024		01/01/2024
Contract Detail	DRUGCO DISCOUNT PHARMACY	139 ELAMS RD		LITTLETON	NC	27850-8479	10/26/2011	10/26/2011	01/18/2016	01/18/2016
Contract Detail	DRUGCO DISCOUNT PHARMACY	312 ACADEMY ST S		AHOSKIE	NC	27910-3200	10/26/2011	10/26/2011	01/18/2016	01/18/2016
Contract Detail	DRUGCO DISCOUNT PHARMACY	139 ELAMS RD		LITTLETON	NC	27850-8479	01/16/2024	04/01/2024		04/01/2024
Contract Detail	DRUGCO HEALTH	107 SMITH CHURCH RD.	SUITE A	ROANOKE RAPIDS	NC	27870	10/26/2011	10/26/2011	09/15/2016	09/15/2016
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03387	1124 E 10TH ST	ROANOKE RAPIDS	NC	27870	10/13/2023	01/01/2024		01/01/2024
Contract Detail	PITT COUNTY MEMORIAL HOSPITAL	D/B/A ECU HEALTH SPECIALTY PHARMACY	2100 STANTONSBURG RD RM 1CC-1105	GREENVILLE	NC	27834	10/13/2022	01/01/2023	09/30/2023	10/13/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/13/2023	01/01/2024		01/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/13/2023	01/01/2024		01/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/13/2023	01/01/2024		01/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #48611	141 PREBLE STREET	PORTLAND	ME	04101	10/13/2023	01/01/2024		01/01/2024
Contract Detail	PROCARE PHARMACY, L.L.C.	CVS/PHARMACY #48637	2700 NORTHEAST EXPY NE STE B800 BUILDING B	ATLANTA	GA	30345	10/13/2023	01/01/2024		01/01/2024
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	10/13/2023	01/01/2024		01/01/2024
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	10/13/2023	01/01/2024		01/01/2024
Contract Detail	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	10/13/2023	01/01/2024		01/01/2024
Contract Detail	UHS EMPLOYEE PHARMACY	D/B/A ECU HEALTH EMPLOYEE PHARMACY	2000 VENTURE TOWER DR P O BOX 6028	GREENVILLE	NC	27834	01/17/2023	04/01/2023		04/01/2023
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16405	1500 E 3RD ST STE A	CHARLOTTE	NC	28204	10/13/2023	01/01/2024		01/01/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07475	101 SMITH CHURCH ROAD	ROANOKE RAPIDS	NC	27870-4911	10/13/2023	01/01/2024		01/01/2024
Contract Detail	Walgreens #21420	Walgreens Central Fill #21420	8440 Times Dispatch Blvd Ste. 400	Mechanicsville	VA	23116	10/13/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/13/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/13/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/13/2023	01/01/2024		01/01/2024
Contract Detail	WH PHARMACY 1, LLC.	DBA DRUGCO DISCOUNT PHARMACY - TARBORO	1507 N MAIN ST	TARBORO	NC	27886	01/16/2024	04/01/2024		04/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH340151A	Child	DSH	Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital	MRI	210 Smith Church Road	Roanoke Rapids	NC	Active
DSH340151B	Child	DSH	Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital	The Wound Care Center	244A Smith Church Road	Roanoke Rapids	NC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Campbell, Dennis President (interim) ECU Health- North Hospital 2525358115	Hickey, Ryan Todd President ECU Health North Hospital 2525358159	2/25/2025 6:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2024 9:00 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	12/13/2024 9:00 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	12/13/2024 9:00 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	12/13/2024 9:00 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	12/13/2024 9:00 AM
Contacts	Primary Contact	Update	Profile Change Request	Bennett, Amy Pharmacy Director ECU Health North Hospital 2525358274	Bennett, Amy Pharmacy Manager ECU Health North Hospital 2525358274	10/28/2024 9:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/22/2024 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/22/2024 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	8/22/2024 8:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/22/2024 8:44 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/22/2024 8:44 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	8/22/2024 8:44 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/22/2024 8:44 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/22/2024 8:44 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/22/2024 8:44 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/22/2024 8:44 AM
Details	Last Recertification Date	Update	Recertification	9/1/2023 6:33:34 PM	8/22/2024 8:44:13 AM	8/22/2024 8:44 AM
Contacts	Authorizing Official	Update	AO Change Request	Harrell, Jason President ECU Health North Hospital 2525358115	Campbell, Dennis President (interim) ECU Health- North Hospital 2525358115	8/13/2024 12:13 PM
Details	Last Recertification Date	Update	Recertification	9/19/2022 11:03:56 AM	9/1/2023 6:33:34 PM	9/1/2023 6:33 PM
Contacts	Primary Contact	Update	Change Request	Bennett, Amy Pharmacy Director Halifax Regional Medical Center 2525358274	Bennett, Amy Pharmacy Director ECU Health North Hospital 2525358274	6/1/2023 7:42 AM
Contacts	Authorizing Official	Update	Change Request	Harrell, Jason Barnes President Halifax Regional Medical Center 2525358159	Harrell, Jason President ECU Health North Hospital 2525358115	6/1/2023 7:42 AM
Details	Last Recertification Date	Update	Recertification	9/14/2021 2:52:55 PM	9/19/2022 11:03:56 AM	9/19/2022 11:03 AM
Details	Entity Name	Update	Change Request	HALIFAX REGIONAL MEDICAL CENTER, INC., D/B/A VIDANT NORTH HOSPITAL	Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital	6/23/2022 7:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (MI)		9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (GA)		9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (CT)		9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (IL)		9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (IN)		9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		UT	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (MI)		9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (GA)		9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (CT)		9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (IL)		9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (IN)		9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/14/2021 2:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	9/14/2021 2:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/14/2021 2:52 PM
Details	Last Recertification Date	Update	Recertification	8/17/2020 1:08:27 PM	9/14/2021 2:52:55 PM	9/14/2021 2:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	9/11/2020 8:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		CT	9/11/2020 8:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	9/11/2020 8:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	9/11/2020 8:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	9/11/2020 8:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	9/11/2020 8:55 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:55 AM
Medicaid Billing	NPI: State	Insert	Change Request		MA	9/11/2020 8:55 AM
Contacts	Authorizing Official	Update	Change Request	Mahone, William President Halifax Regional Medical Center 2525358111	Harrell, Jason Barnes President Halifax Regional Medical Center 2525358159	9/4/2020 9:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 1:08 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:08 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 ( )		8/17/2020 1:08 PM
Details	Last Recertification Date	Update	Recertification	9/10/2019 11:21:36 AM	8/17/2020 1:08:27 PM	8/17/2020 1:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DC	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/28/2020 7:28 AM
Details	Entity Name	Update	Change Request	HALIFAX REGIONAL MEDICAL CENTER	HALIFAX REGIONAL MEDICAL CENTER, INC., D/B/A VIDANT NORTH HOSPITAL	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (CA)		9/10/2019 11:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (WV)		9/10/2019 11:21 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 3:32:59 PM	9/10/2019 11:21:36 AM	9/10/2019 11:21 AM
Contacts	Primary Contact	Update	Change Request	Bennett, Amy Tromans Director of Pharmacy Halifax Regional Medical Center 2525358274	Bennett, Amy Pharmacy Director Halifax Regional Medical Center 2525358274	6/11/2019 9:22 AM
Contacts	Authorizing Official	Update	Change Request	Mahone, William CEO Halifax Regional Medical Center 2525358011	Mahone, William President Halifax Regional Medical Center 2525358111	6/11/2019 9:22 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	092444000	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000280607X (GA)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	424745100	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110027713B (MA)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	4175905 (NJ)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	00352685	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0007897300001 (PA)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	272280 (SC)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	10025A	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	009810331	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	3400151	1346273943	6/7/2019 10:10 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1558407585 ( )		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	009810331 (VA)		11/12/2018 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		092444000	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000280607X	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		424745100	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110027713B	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4175905	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00352685	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0007897300001	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		272280	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10025A	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		009810331	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		009810331	11/12/2018 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	11/12/2018 3:00 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558407585	11/12/2018 3:00 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 10:52:03 AM	8/22/2018 3:32:59 PM	8/22/2018 3:32 PM
Contacts	Primary Contact	Update	Profile Change Request	Bennett, Amy Tromans Director of Pharmacy Halifax Regional Medical Center 2525358761	Bennett, Amy Tromans Director of Pharmacy Halifax Regional Medical Center 2525358274	8/21/2018 3:18 PM
Contacts	Primary Contact	Update	Change Request	Lehman, David Christian Director of Pharmacy Services Halifax Regional Medical Center 2525358274	Bennett, Amy Tromans Director of Pharmacy Halifax Regional Medical Center 2525358761	6/29/2018 10:17 AM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	11/15/2017 10:52:03 AM	11/15/2017 10:52 AM
Contacts	Primary Contact	Update	Profile Change Request	Lehman, Christian Christian Director of Pharmacy Services Halifax Regional Medical Center 2525358274	Lehman, David Christian Director of Pharmacy Services Halifax Regional Medical Center 2525358274	11/2/2017 3:20 PM
Contacts	Primary Contact	Update		Lehman, Christian Director of Pharmacy Services 2525358274	Lehman, Christian Christian Director of Pharmacy Services Halifax Regional Medical Center 2525358274	11/2/2017 8:57 AM
Contacts	Primary Contact	Insert			Lehman, Christian Director of Pharmacy Services 2525358274	9/15/2016 1:37 PM
Contacts	Authorizing Official	Insert			Mahone, William CEO Halifax Regional Medical Center 2525358011	8/29/2016 12:01 PM
Addresses	Main Address	Insert			250 SMITH CHURCH ROAD ROANOKE RAPIDS, NC 27870	8/29/2016 11:55 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 11:55 AM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/5/2015 11:05 AM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 11:05 AM
Details	Last Recertification Date	Update		8/21/2013 12:00:00 AM	8/7/2014 12:00:00 AM	8/7/2014 2:25 PM
Dates	Participating Approval Date	Update		4/23/2008 11:13:25 AM	4/23/2008 12:00:00 AM	8/21/2013 2:11 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/21/2013 12:00:00 AM	8/21/2013 2:11 PM
Medicaid Billing	NPI: Number	Insert			1346273943	5/21/2012 7:40 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/21/2012 7:40 AM
Details	Last Recertification Date	Insert				4/23/2008 11:16 AM
Details	Grant Number	Insert				4/23/2008 11:16 AM
Details	340B ID	Insert			DSH340151	4/23/2008 11:16 AM
Details	Is Authorizing Official EHB Data	Insert				4/23/2008 11:16 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/23/2008 11:16 AM
Details	Medicare Provider Number	Insert			340151	4/23/2008 11:16 AM
Details	Entity Name	Insert			HALIFAX REGIONAL MEDICAL CENTER	4/23/2008 11:16 AM
Details	Program Code	Insert			DSH	4/23/2008 11:16 AM
Details	Entity Subname	Insert				4/23/2008 11:16 AM
Dates	Participating Approval Date	Insert			4/23/2008 11:13:25 AM	4/23/2008 11:16 AM
Details	State	Insert			Active	4/23/2008 11:16 AM
Dates	Registration Date	Insert			4/23/2008 12:00:00 AM	4/23/2008 11:16 AM
Dates	Signed By Date	Insert				4/23/2008 11:16 AM
Dates	Start Date	Insert			7/1/2004 12:00:00 AM	4/23/2008 11:16 AM
Terminations	Termination Comments	Insert				4/23/2008 11:16 AM
Terminations	Termination Date	Insert				4/23/2008 11:16 AM
Terminations	Termination Effective Date	Insert				4/23/2008 11:16 AM
Terminations	Termination Reason	Insert				4/23/2008 11:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert			True	4/23/2008 11:16 AM
Medicaid Billing	Medicaid: Number	Insert			3400151	4/23/2008 11:16 AM
Medicaid Billing	Medicaid: State	Insert			NC	4/23/2008 11:16 AM