Covered Entity Details

DSH340127 GRANVILLE MEDICAL CENTER (Active) - information as of 6/23/2025 12:24:51 AM

Main Details

Name

GRANVILLE MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340127

Medicare Provider Number

340127

Additional Details

Current Program Status

Active

Registration Date

4/29/2008

Participating Start Date

7/1/2004

Participating Approval Date

4/29/2008

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

Granville Health System
Adam West McConnell, CEO
(919) 690-3402

Primary Contact

Granville Health System
Lynda Wrenn Beasley, Interim Director of Pharmacy
(919) 690-3000 Ext: 3471

Addresses

Street Address

1010 COLLEGE STREET
OXFORD, NC 27565

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
NC	3400127	1326061730
VA	3400127	1326061730

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	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/14/2021	04/01/2021	07/09/2024	07/09/2024
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/14/2021	04/01/2021	07/09/2024	07/09/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/14/2021	04/01/2021	07/09/2024	07/09/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/14/2021	04/01/2021	07/09/2024	07/09/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/14/2021	04/01/2021	07/09/2024	07/09/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/14/2021	04/01/2021	07/09/2024	07/09/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CCRX OF NORTH CAROLINA, LLC	OMNICARE OF RALEIGH	1815 GARNER STATION BOULEVARD	RALEIGH	NC	27603	10/13/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CREEDMOOR DRUG COMPANY	108 NORTH MAIN ST	PO BOX 523	CREEDMOOR	NC	27522	10/14/2013	01/01/2014	07/27/2021	08/23/2021
Contract Detail	CVS STATE CAPITAL, L.L.C.	DBA: CVS/PHARMACY # 08245	10 MIDDLE STREET	FREEPORT	ME	04032	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	CVS TN DISTRIBUTION, LLC	10017 KINGSTON PIKE		KNOXVILLE	TN	37922	10/10/2014	01/01/2015	08/15/2018	08/15/2018
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	01/15/2019	04/01/2019		04/01/2019
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/09/2021	07/01/2021		07/01/2021
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/09/2021	07/01/2021		07/01/2021
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/09/2021	07/01/2021		07/01/2021
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/09/2021	07/01/2021		07/01/2021
Contract Detail	FOOD LION LLC	DBA: FOOD LION PHARMACY #1228	1263 DABNEY DR	HENDERSON	NC	27536-3558	07/14/2020	10/01/2020	06/23/2024	06/23/2024
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 00536	3187 S CONGRESS AVE	PALM SPRINGS	FL	33461	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	MAST FAMILY DRUG CENTER	418 DABNEY DR		HENDERSON	NC	27536-3944	07/13/2016	10/01/2016		07/13/2016
Contract Detail	MEDICAL ARTS PHARMACY	253 RUIN CREEK RD		HENDERSON	NC	27536	04/17/2015	07/01/2015		04/17/2015
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01246	612 N. MAIN ST.	CREEDMOOR	NC	27522	10/11/2013	01/01/2014	10/04/2022	10/12/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03985	215 WILLIAMSBORO ST	OXFORD	NC	27565	10/11/2013	01/01/2014	10/04/2022	10/12/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07055	109 DABNEY DR.	HENDERSON	NC	27536	10/26/2016	01/01/2017	10/04/2022	10/12/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03831	102 N. BICKETT BLVD.	LOUISBURG	NC	27549	04/12/2019	07/01/2019	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08959	1190 US 1 HWY	YOUNGSVILLE	NC	27596	04/12/2019	07/01/2019	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03531	900 N MADISON BLVD	ROXBORO	NC	27573	04/06/2020	05/05/2020	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02306	2797 HWY 55	CARY	NC	27519	05/06/2020	05/06/2020	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03214	5680 NC HIGHWAY 42 WEST	GARNER	NC	27529	05/06/2020	05/06/2020	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05313	13304 LEESVILLE CHURCH ROAD	RALEIGH	NC	27617	05/06/2020	05/06/2020	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY #07513	4309 NEW BERN AVE (NWC)	RALEIGH	NC	27610	05/06/2020	05/06/2020	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #10863	2411 LANDMARK DR.	RALEIGH	NC	27607	05/06/2020	05/06/2020	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #7959	4000 BATTLEGROUND AVE.	GREENSBORO	NC	27410	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07053	904 SOUTH 5TH ST.	MEBANE	NC	27302	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00317	5859 TRYON ROAD	CARY	NC	27518	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05042	1990 NW CARY PKWY.	MORRISVILLE	NC	27560	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #10682	3001 HILLSBOROUGH ST., SUITE 100	RALEIGH	NC	27607	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07555	2902 FORESTVILLE RD.	RALEIGH	NC	27616	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06988	11000 CREEDMOOR RD.	RALEIGH	NC	27614	10/13/2020	01/01/2021	10/04/2022	10/12/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02313	2340 SPRING FOREST ROAD	RALEIGH	NC	27615	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03833	200 N GREENSBORO ST.	CARRBORO	NC	27510	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	PHARMACY CONSULTANTS, LLC	D/B/A OMNICARE OF SPARTANBURG	111 CORPORATE DR STE L	SPARTANBURG	SC	29303	10/13/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	01/15/2019	04/01/2019	10/01/2022	10/18/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/14/2020	01/01/2021	08/12/2021	08/23/2021
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	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/14/2020	01/01/2021	08/12/2021	08/23/2021
Contract Detail	PROFESSIONAL PHARMACY	140 ROXBORO RD.		OXFORD	NC	27565	01/08/2013	04/01/2013	02/28/2023	06/19/2024
Contract Detail	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05736	24 GATEWAY LN.	CLARKSVILLE	VA	23927	04/12/2019	07/01/2019	10/04/2022	10/12/2022
Contract Detail	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03915	610 N MAIN ST	CHASE CITY	VA	23924	10/11/2019	01/01/2020	05/20/2021	08/23/2021
Contract Detail	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05507	807 E ATLANTIC ST	SOUTH HILL	VA	23970	04/06/2020	05/05/2020	05/20/2021	08/23/2021
Contract Detail	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01559	919 SOUTH MAIN ST	FARMVILLE	VA	23901	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05729	3231 HALIFAX ROAD	SOUTH BOSTON	VA	24592	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07510	1425 S. BOSTON RD.	DANVILLE	VA	24540	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/24/2017	04/01/2017		01/24/2017
Contract Detail	WAL-MART PHARMACY 10-1579	1015 LEWIS ST		OXFORD	NC	27565	09/19/2012	09/19/2012		03/28/2013
Contract Detail	WAL-MART PHARMACY 10-2256	200 N COOPER DR		HENDERSON	NC	27536	04/01/2014	07/01/2014		04/01/2014
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	07/14/2020	10/01/2020		10/01/2020
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/24/2017	04/01/2017		01/24/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12630	201 HILLSBORO ST.	OXFORD	NC	27565	01/15/2019	04/01/2019		04/01/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07398	1411 OXFORD ROAD	HENDERSON	NC	27536-4967	01/15/2019	04/01/2019		04/01/2019
Contract Detail	WALGREEN CO.	DBA WALGREENS #15551	703 NORTH MAIN STREET	CREEDMOOR	NC	27522	01/15/2019	04/01/2019	11/07/2019	11/13/2019
Contract Detail	WALGREEN CO.	WALGREENS #16150	126 E MACON ST	WARRENTON	NC	27589	01/15/2019	04/01/2019		04/01/2019
Contract Detail	WALGREEN CO.	WALGREENS #19475	1560 NC HIGHWAY 56	CREEDMOOR	NC	27522	10/11/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	WALGREENS #19096	201 TRADE ST	HENDERSON	NC	27536	10/23/2024	01/01/2025		01/01/2025
Contract Detail	Walgreens #21420	Walgreens Central Fill #21420	8440 Times Dispatch Blvd Ste. 400	Mechanicsville	VA	23116	07/13/2023	10/01/2023		10/01/2023
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	01/15/2019	04/01/2019		04/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	01/15/2019	04/01/2019	10/01/2021	10/15/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	01/15/2019	04/01/2019		04/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	01/15/2019	04/01/2019		04/01/2019
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	01/15/2019	04/01/2019		04/01/2019
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	01/15/2019	04/01/2019		04/01/2019
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/14/2023	07/01/2023		07/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/13/2023	01/01/2024		01/01/2024
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04167	700 NORTHSIDE DR.	SUMMERSVILLE	WV	26651	10/13/2020	01/01/2021	05/20/2021	08/23/2021
Contract Detail	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08162	2045 SOUTH BLVD W	TROY	MI	48098-6540	05/06/2020	05/06/2020	05/20/2021	08/23/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH340127A	Child	DSH	GRANVILLE MEDICAL CENTER	GRANVILLE INTERNAL MEDICINE AND GER	110 Professional Park Drive	OXFORD	NC	Active
DSH340127B	Child	DSH	GRANVILLE MEDICAL CENTER	SOUTH GRANVILLE PRIMARY CARE	1614 NC Highway 56	Creedmoor	NC	Active
DSH340127C	Child	DSH	GRANVILLE MEDICAL CENTER	GRANVILLE BEHAVIORAL HEALTH SERVICE	102 Professional Park Drive	OXFORD	NC	Active
DSH340127D	Child	DSH	GRANVILLE MEDICAL CENTER	Granville Heart & Vascular	102 Professional Park Drive, Suite C	Oxford	NC	Terminated
DSH340127E	Child	DSH	GRANVILLE MEDICAL CENTER	Granville Urology Associates	102 Professional Park Drive	Oxford	NC	Terminated
DSH340127F	Child	DSH	GRANVILLE MEDICAL CENTER	Stovall Medical Center	100 Durham Street	Stovall	NC	Terminated
DSH340127G	Child	DSH	GRANVILLE MEDICAL CENTER	Granville Surgical Associates	102 Professional Park Drive	Oxford	NC	Terminated
DSH340127H	Child	DSH	GRANVILLE MEDICAL CENTER	GRANVILLE SPECIALTY CLINIC	103 PROFESSIONAL PARK	OXFORD	NC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/22/2023 10:58:12 AM	8/23/2024 10:18:01 AM	8/23/2024 10:18 AM
Contacts	Primary Contact	Update	Change Request	Torrence, Tara Pharmacy Director Granville Health System 9196903471	Beasley, Lynda Wrenn Interim Director of Pharmacy Granville Health System 9196903000-3471	6/3/2024 4:17 PM
Contacts	Authorizing Official	Update	Profile Change Request	McConnell, Adam West CFO Granville Health System 9196903402	McConnell, Adam West CEO Granville Health System 9196903402	4/1/2024 10:15 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 1:38:54 PM	8/22/2023 10:58:12 AM	8/22/2023 10:58 AM
Details	Last Recertification Date	Update	Recertification	8/23/2021 11:52:57 AM	8/29/2022 1:38:54 PM	8/29/2022 1:38 PM
Details	Last Recertification Date	Update	Recertification	8/21/2020 10:45:19 AM	8/23/2021 11:52:57 AM	8/23/2021 11:52 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/21/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3400127	8/21/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	8/21/2020 10:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/21/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3400127	8/21/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	8/21/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	340127 (NC)		8/21/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1326061730	8/21/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/21/2020 10:45 AM
Medicaid Billing	NPI: State	Update	Recertification		VA	8/21/2020 10:45 AM
Details	Last Recertification Date	Update	Recertification	8/20/2019 11:20:43 AM	8/21/2020 10:45:19 AM	8/21/2020 10:45 AM
Contacts	Primary Contact	Update	Change Request	Thomas, Scott Vice President HR & Communication Granville Health System 9196903459	Torrence, Tara Pharmacy Director Granville Health System 9196903471	11/12/2019 2:17 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 7:53:00 AM	8/20/2019 11:20:43 AM	8/20/2019 11:20 AM
Contacts	Primary Contact	Update	Recertification	Ellixson, Catherine Pharmacy Systems Analyst Granville Health System 9196903468	Thomas, Scott Vice President HR & Communication Granville Health System 9196903459	8/24/2018 7:53 AM
Details	Last Recertification Date	Update	Recertification	12/1/2017 3:31:03 PM	8/24/2018 7:53:00 AM	8/24/2018 7:53 AM
Contacts	Authorizing Official	Update	AO Change Request	Armstrong, Jeffery M. CFO Granville Health System 9196903402	McConnell, Adam West CFO Granville Health System 9196903402	3/14/2018 3:50 PM
Details	Last Recertification Date	Update	Recertification	9/1/2016 12:00:00 AM	12/1/2017 3:31:03 PM	12/1/2017 3:31 PM
Contacts	Primary Contact	Update	Recertification	Ellixson, Catherine Pharmacy Systems Analyst 9196903468	Ellixson, Catherine Pharmacy Systems Analyst Granville Health System 9196903468	12/1/2017 2:20 PM
Contacts	Authorizing Official	Update		Armstrong, Jeffery M. CFO 9196903402	Armstrong, Jeffery M. CFO Granville Health System 9196903402	10/2/2017 12:47 PM
Contacts	Authorizing Official	Insert			Armstrong, Jeffery M. CFO 9196903402	1/24/2017 1:21 PM
Addresses	Main Address	Insert			1010 COLLEGE STREET OXFORD, NC 27565	9/2/2016 4:15 PM
Contacts	Primary Contact	Update		Stancil, John DIRECTOR OF PHARMACY 9196903411	Ellixson, Catherine Pharmacy Systems Analyst 9196903468	9/2/2016 4:15 PM
Details	Last Recertification Date	Update		9/4/2015 12:00:00 AM	9/1/2016 12:00:00 AM	9/2/2016 4:15 PM
Details	Last Recertification Date	Update		9/10/2014 12:00:00 AM	9/4/2015 12:00:00 AM	9/4/2015 3:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/10/2014 10:31 AM
Medicaid Billing	Medicaid: Number	Insert			340127	9/10/2014 10:31 AM
Medicaid Billing	Medicaid: State	Insert			NC	9/10/2014 10:31 AM
Medicaid Billing	NPI: Number	Insert			1326061730	9/10/2014 10:31 AM
Details	Last Recertification Date	Update		9/3/2013 12:00:00 AM	9/10/2014 12:00:00 AM	9/10/2014 10:31 AM
Contacts	Primary Contact	Insert			Stancil, John DIRECTOR OF PHARMACY 9196903411	9/8/2014 7:46 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/3/2013 12:00:00 AM	9/3/2013 4:17 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/21/2012 7:42 AM
Details	Last Recertification Date	Insert				4/29/2008 1:19 PM
Details	Grant Number	Insert				4/29/2008 1:19 PM
Details	340B ID	Insert			DSH340127	4/29/2008 1:19 PM
Details	Is Authorizing Official EHB Data	Insert				4/29/2008 1:19 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/29/2008 1:19 PM
Details	Medicare Provider Number	Insert			340127	4/29/2008 1:19 PM
Details	Entity Name	Insert			GRANVILLE MEDICAL CENTER	4/29/2008 1:19 PM
Details	Program Code	Insert			DSH	4/29/2008 1:19 PM
Details	Entity Subname	Insert				4/29/2008 1:19 PM
Dates	Participating Approval Date	Insert			4/29/2008 1:15:52 PM	4/29/2008 1:19 PM
Details	State	Insert			Active	4/29/2008 1:19 PM
Dates	Registration Date	Insert			4/29/2008 12:00:00 AM	4/29/2008 1:19 PM
Dates	Signed By Date	Insert				4/29/2008 1:19 PM
Dates	Start Date	Insert			7/1/2004 12:00:00 AM	4/29/2008 1:19 PM
Terminations	Termination Comments	Insert				4/29/2008 1:19 PM
Terminations	Termination Date	Insert				4/29/2008 1:19 PM
Terminations	Termination Effective Date	Insert				4/29/2008 1:19 PM
Terminations	Termination Reason	Insert				4/29/2008 1:19 PM