Covered Entity Details

DSH510022 CHARLESTON AREA MEDICAL CENTER (CAMC) (Active) - information as of 5/17/2025 10:47:06 PM

Main Details

Name

CHARLESTON AREA MEDICAL CENTER (CAMC)

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH510022

Medicare Provider Number

510022

Additional Details

Current Program Status

Active

Registration Date

7/8/2008

Participating Start Date

9/22/2005

Participating Approval Date

7/8/2008

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

CAMC Health System
Jeff D Sandene, EVP CFO
(304) 388-7603

Primary Contact

Vandalia Health
Brian Sayre, VP of Pharmacy Services
(304) 388-8917

Addresses

Street Address

501 MORRIS STREET
CHARLESTON, WV 25301

Billing Address

CAMC Accounts Payable
PO Box 2069
Charleston, WV 25301

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
1/21/2011- ADDED SHIP TO; ORIG PART 7/1/03-6/30/05, NOT ELIG 7/1/05-9/21/05	01/21/2011

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
WV		1952390239,1326253592,1427270586,1396965927,1316101819,1073529616,1245544527,1053693697,1033482443,1205978509,1912247750,1134518186,1639168693,1588875595,1124248752,1427627058,1265421226,1487439683,1518579689

Shipping Addresses

Shipping Address 1

CAMC SOLUTIONS
2568 PENNSYLVANIA AVENUE
CHARLESTON, WV 25302

Shipping Address 2

CAMC Women & Childrens Pharmacy
800 Pennsylvania Avenue
Charleston, WV 25302

Shipping Address 3

CAMC Oncology Pharmacy Services
3415 MacCorkle Ave SE
Charleston, WV 25304

Shipping Address 4

CAMC Pharmacy #3
3415 MacCorkle Ave SE
Charleston, WV 25304

Shipping Address 5

CAMC Memorial Pharmacy
3200 MacCorkle Avenue SE
Charleston, WV 25304

Shipping Address 6

CAMC Nuclear Pharmacy
3200 MacCorkle Ave SE
Charleston, WV 25304

Shipping Address 7

CAMC Teays Valley Pharmacy
1400 Hospital Drive
Hurricane, WV 25526

Shipping Address 8

CAMC Pharmacy
3200 MacCorkle Ave SE
Charleston, WV 25304

Shipping Address 9

CAMC General Pharmacy
501 Morris Street
Charleston, WV 25301

Shipping Address 10

Safecor Health, LLC
4060 Business Park Drive, Suite B
Columbus, OH 43204

Shipping Address 11

CAMC Pharmacy #2
501 Morris St.
Charleston, WV 25301

Shipping Address 12

Safecor Health, LLC.
317 New Boston Street
Woburn, MA 01801

Shipping Address 13

CAMC Pharmacy #4
3948 Teays Valley Road
Hurricane, WV 25526

Shipping Address 14

CAMC Pharmacy #5
400 Association Drive
Charleston, WV 25311-1295

Shipping Address 15

CAMC Pharmacy South Charleston
4610 Kanawha Ave. SW
South Charleston, WV 25309

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	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	10/17/2016	01/01/2017	02/27/2020	03/02/2020
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/17/2016	01/01/2017		07/28/2017
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/17/2016	01/01/2017		07/28/2017
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/15/2021	10/01/2021		10/01/2021
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	10/17/2016	01/01/2017	06/01/2023	08/10/2023
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/17/2016	01/01/2017		07/28/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/17/2016	01/01/2017		07/28/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	11411 STRANG LINE RD	STE A	LENEXA	KS	66215	04/08/2022	07/01/2022		07/01/2022
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/19/2023	07/01/2023		07/01/2023
Contract Detail	AVELLA OF COLUMBUS	4830 KNIGHTSBRIDGE BLVD STE C		COLUMBUS	OH	43214-2300	01/09/2018	04/01/2018	07/01/2020	07/02/2020
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	01/09/2018	04/01/2018	07/02/2020	07/14/2020
Contract Detail	AVELLA OF ORLANDO	100 TECHNOLOGY PARK STE 155		LAKE MARY	FL	32746-6205	01/15/2018	04/01/2018	10/31/2022	11/05/2022
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	04/15/2024	07/01/2024		07/01/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	01/03/2025	04/01/2025		04/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	01/03/2025	04/01/2025		04/01/2025
Contract Detail	BIOSCRIP INFUSION SERVICES, LLC	DBA BIOSCRIP INFUSION SERVICES	4401 MACCORKLE AVE SE	CHARLESTON	WV	25304	01/14/2020	04/01/2020		04/01/2020
Contract Detail	BIOSCRIP PHARMACY SERVICES, INC.	BIOSCRIP PHARMACY SERVICES	5700 PERIMETER DR STE B	DUBLIN	OH	43017	01/14/2020	04/01/2020		04/01/2020
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/13/2017	07/01/2017		07/28/2017
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/16/2024	04/01/2024		04/01/2024
Contract Detail	CENTERWELL PHARMACY, INC.	10737 MARKS WAY		MIRAMAR	FL	33025	04/14/2021	07/01/2021		07/01/2021
Contract Detail	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	04/14/2021	07/01/2021		07/01/2021
Contract Detail	CLAIRE-FRANCES HEALTH SERVICE	DBA INFUSION SOLUTIONS	1557 WINCHESTER AVE	ASHLAND	KY	41101-7636	04/14/2017	07/01/2017	01/01/2019	01/03/2019
Contract Detail	CLAIRE-FRANCES HEALTH SERVICES	DBA INFUSION SOLUTIONS	5528 MACCORKLE AVE SE SUITE 101	CHARLESTON	WV	25304	04/14/2017	07/01/2017	01/01/2019	01/03/2019
Contract Detail	CMC PHARMACY, LLC	BIOMATRIX SPECIALTY PHARMACY WV	3100 MACCORKLE AVE SE STE 100	CHARLESTON	WV	25304-1215	10/17/2016	01/01/2017	02/17/2023	02/17/2023
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/08/2021	01/01/2022		01/01/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/08/2021	01/01/2022		01/01/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/16/2024	04/01/2024		04/01/2024
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/11/2018	07/01/2018	10/13/2023	10/15/2023
Contract Detail	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	04/15/2024	07/01/2024		07/01/2024
Contract Detail	DRUG EMPORIUM	5101 MACCORKLE AVE SE		CHARLESTON	WV	25304-2148	10/16/2022	01/01/2023	09/12/2024	09/30/2024
Contract Detail	DRUG EMPORIUM	1603 KANAWHA BLVD WEST		CHARLESTON	WV	25387	10/16/2022	01/01/2023	09/12/2024	09/30/2024
Contract Detail	FRUTH	FRUTH PHARMACY #20	501 ROOSEVELT BLVD	ELEANOR	WV	25070	01/03/2019	04/01/2019	06/22/2024	06/28/2024
Contract Detail	FRUTH	FRUTH PHARMACY #19	509 SOUTH CHURCH STREET	RIPLEY	WV	25271	01/14/2019	04/01/2019		04/01/2019
Contract Detail	FRUTH PHARMACY	FRUTH PHARMACY #14	DBA FRUTH PHCY OAKWOOD RD 864 OAKWOOD RD	CHARLESTON	WV	25314-2010	01/03/2019	04/01/2019		04/01/2019
Contract Detail	FRUTH PHARMACY	FRUTH PHARMACY #13	DBA FRUTH PHCY OF WINFIELD 12803 WINFIELD RD	WINFIELD	WV	25213-9608	01/03/2019	04/01/2019		04/01/2019
Contract Detail	FRUTH PHARMACY #23	FRUTH PHARMACY #23	4539 TEAYS VALLEY ROAD	SCOTT DEPOT	WV	25560-7806	01/03/2019	04/01/2019		04/01/2019
Contract Detail	FRUTH PHARMACY #25	FRUTH EXPRESS	701 LEE STREET	CHARLESTON	WV	25301	01/03/2019	04/01/2019	02/12/2025	02/12/2025
Contract Detail	FRUTH PHARMACY OF HURRICANE	FRUTH PHARMACY #10	3109 TEAYS VALLEY RD	HURRICANE	WV	25526	01/03/2019	04/01/2019		04/01/2019
Contract Detail	FRUTH PHARMACY OF NITRO INC	FRUTH PHARMACY #7	101 21ST STREET	NITRO	WV	25143	01/03/2019	04/01/2019		04/01/2019
Contract Detail	I.G.G. of AMERICA, Inc. d/b/a US Bioservices	514 PROGRESS DRIVE	SUITE X	LINTHICUM	MD	21090	07/02/2010	07/02/2010	09/01/2022	09/01/2022
Contract Detail	KROGER #763	5450 BIG TYLER ROAD		CROSS LANES	WV	25313	01/14/2016	04/01/2016		11/15/2018
Contract Detail	KROGER COLUMBUS CENTRAL FILL #019	2270 RICKENBACKER PKWY W		COLUMBUS	OH	43217	04/10/2024	07/01/2024		07/01/2024
Contract Detail	KROGER PHARMACY	500 DELAWARE AVE		CHARLESTON	WV	25302	01/14/2016	04/01/2016		11/15/2018
Contract Detail	KROGER PHARMACY	1100 FLEDDERJOHN RD		CHARLESTON	WV	25314	01/14/2016	04/01/2016		11/15/2018
Contract Detail	KROGER PHARMACY	505 VIRGINIA AVE		SMITHERS	WV	25186	01/14/2016	04/01/2016	02/08/2019	02/08/2019
Contract Detail	KROGER PHARMACY #688	788 WEST PIKE STREET		CLARKSBURG	WV	26301	01/14/2016	04/01/2016	08/03/2018	11/15/2018
Contract Detail	KROGER PHARMACY #708	106 MCGRAW STREET		RIPLEY	WV	25271	01/14/2016	04/01/2016	08/03/2018	11/15/2018
Contract Detail	KROGER PHARMACY #725	1439 MACCORKLE AVENUE		ST ALBANS	WV	25177	01/14/2016	04/01/2016		11/15/2018
Contract Detail	KROGER PHARMACY #768	981 DUNBAR VILLAGE		DUNBAR	WV	25064	01/14/2016	04/01/2016		11/15/2018
Contract Detail	KROGER PHARMACY #769	5 RIVERWALK MALL		SOUTH CHARLESTON	WV	25303	01/14/2016	04/01/2016		11/15/2018
Contract Detail	KROGER PHARMACY #794	101 GREAT TEAYS BLVD.		SCOTT DEPOT	WV	25560	01/14/2016	04/01/2016		11/15/2018
Contract Detail	KROGER PHARMACY #817	3265 SMOOT AVE		DANVILLE	WV	25053	01/14/2016	04/01/2016	08/03/2018	11/15/2018
Contract Detail	OPTION CARE ENTERPRISES, INC.	D/B/A OPTION CARE	11403 BLUEGRASS PARKWAY SUITE 400	LOUISVILLE	KY	40299-2398	01/14/2020	04/01/2020		04/01/2020
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/16/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	10/16/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM INFUSION SERVICES 201, INC.	5700 DOT COM CT STE 1030		OVIEDO	FL	32765-3400	01/16/2022	04/01/2022	04/20/2023	04/20/2023
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	4000 CHEMICAL RD STE 100		PLYMOUTH MEETING	PA	19462	01/16/2022	04/01/2022		04/01/2022
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	01/16/2022	04/01/2022		04/01/2022
Contract Detail	OPTUM INFUSION SERVICES 500, INC.	4900 RIVERGRADE RD STE E120		IRWINDALE	CA	91706-1419	01/16/2022	04/01/2022	08/02/2022	08/11/2022
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	7167 E. KEMPER RD.		CINCINNATI	OH	45249	01/16/2022	04/01/2022		04/01/2022
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	1819 ASTON AVE STE 104		CARLSBAD	CA	92008	10/17/2022	01/01/2023		01/01/2023
Contract Detail	OPTUM INFUSION SERVICES 553, LLC	6531 MERIDIEN DR	SUITE 113	RALEIGH	NC	27616	10/16/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/16/2022	01/24/2022		01/25/2022
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/15/2019	01/01/2020		01/01/2020
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/15/2019	01/01/2020		01/01/2020
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/02/2020	07/02/2020		07/13/2020
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/11/2018	07/01/2018	10/01/2022	02/13/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/13/2017	07/01/2017		07/28/2017
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #11338	10160 INTERNATIONAL BLVD.	WEST CHESTER	OH	45246	10/08/2021	01/01/2022		01/01/2022
Contract Detail	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/15/2024	07/01/2024		07/01/2024
Contract Detail	RITE AID OF WEST VIRGINIA, INC.	RITE AID #294	6401 SISSONVILLE DRIVE	CHARLESTON	WV	25312	07/13/2016	10/01/2016	02/09/2018	04/11/2018
Contract Detail	RITE AID OF WEST VIRGINIA, INC.	RITE AID #934	3801 MACCORKLE AVENUE SE	CHARLESTON	WV	25304	07/13/2016	10/01/2016	02/09/2018	04/11/2018
Contract Detail	RITE AID OF WEST VIRGINIA, INC.	RITE AID #935	406 WEST WASHINGTON STREET	CHARLESTON	WV	25302	07/13/2016	10/01/2016	02/09/2018	04/11/2018
Contract Detail	RITE AID OF WEST VIRGINIA, INC.	RITE AID #947	333 MACCORKLE AVENUE,SW	SOUTH CHARLESTON	WV	25303	07/13/2016	10/01/2016	02/09/2018	04/11/2018
Contract Detail	RITE AID OF WEST VIRGINIA, INC.	RITE AID #966	215 STATE ROUTE 34	HURRICANE	WV	25526	07/13/2016	10/01/2016	02/09/2018	04/11/2018
Contract Detail	RITE AID OF WEST VIRGINIA, INC.	RITE AID #2571	4402 PENNSYLVANIA AVENUE	BIG CHIMNEY	WV	25302	07/13/2016	10/01/2016	02/09/2018	04/11/2018
Contract Detail	RITE AID OF WEST VIRGINIA, INC.	RITE AID #3702	932 CROSS LANES DRIVE	CROSS LANES	WV	25313	07/13/2016	10/01/2016	02/09/2018	04/11/2018
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/15/2024	07/01/2024		07/01/2024
Contract Detail	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	04/15/2024	07/01/2024		07/01/2024
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/15/2019	01/01/2020		01/01/2020
Contract Detail	WAL-MART PHARMACY 10-1450	200 ACADEMY DRIVE		RIPLEY	WV	25271	01/15/2016	04/01/2016		07/28/2017
Contract Detail	WAL-MART PHARMACY 10-2036	2700 MOUNTAINEER BLVD		SOUTH CHARLESTON	WV	25309	01/15/2016	04/01/2016		07/28/2017
Contract Detail	WAL-MART PHARMACY 10-2576	100 NITRO MARKETPLACE		CROSS LANES	WV	25313	01/15/2016	04/01/2016		07/28/2017
Contract Detail	WAL-MART PHARMACY 10-4278	1001 WARRIOR WAY		QUINCY	WV	25015	01/15/2016	04/01/2016		07/28/2017
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/15/2019	01/01/2020		01/01/2020
Contract Detail	WALGREEN CO.	WALGREENS #19653	3801 MACCORKLE AVE SE	CHARLESTON	WV	25304-1527	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	RITE AID #00935	406 WASHINGTON ST W	CHARLESTON	WV	25302	04/11/2018	07/01/2018	06/10/2019	06/11/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11750	101 GOFF MOUNTAIN RD.	CROSS LANES	WV	25313	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	WALGREENS #17409	215 STATE ROUTE 34	HURRICANE	WV	25526-7003	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12454	655 WASHINGTON ST. W	CHARLESTON	WV	25302	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	WALGREENS #17738	333 MACCORKLE AVE SW	SOUTH CHARLESTON	WV	25303-1263	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	WALGREENS #19108	4402 PENNSYLVANIA AVE	BIG CHIMNEY	WV	25302-4700	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	RITE AID #03702	932 CROSS LANES DR	CROSS LANES	WV	25313	04/11/2018	07/01/2018	05/08/2019	05/09/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12678	3000 TEAYS VALLEY RD.	HURRICANE	WV	25526	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11978	2933 ROBERT C. BYRD DR.	BECKLEY	WV	25801	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	WALGREENS #17855	6401 SISSONVILLE DR	CHARLESTON	WV	25312-9463	04/11/2018	07/01/2018		04/11/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11981	5870 WEBSTER RD.	SUMMERSVILLE	WV	26651	04/11/2018	07/01/2018	11/06/2023	11/15/2023
Contract Detail	WALGREEN CO.	WALGREENS #17413	1662 SMOOT AVE PO BOX 286	DANVILLE	WV	25053-0286	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	WALGREENS #18275	28 MAIN AVE PO BOX 4547	LOGAN	WV	25601-3331	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	WALGREENS #19790	1101 MYERS AVE	DUNBAR	WV	25064-3118	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	WALGREENS # 18982	100 21ST ST.	NITRO	WV	25143-1740	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	WALGREENS #19209	8699 ELK RIVER RD N	CLENDENIN	WV	25045-0685	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	WALGREENS #17274	101A ROOSEVELT BLVD	ELEANOR	WV	25070-4000	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	WALGREENS #17111	305 6TH AVE	SAINT ALBANS	WV	25177-2838	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	WALGREENS #17353	1301 WASHINGTON ST E	CHARLESTON	WV	25301-1916	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	RITE AID #02736	200 VIRGINIA ST	SMITHERS	WV	25186	04/16/2019	07/01/2019	02/17/2020	02/21/2020
Contract Detail	WALGREEN CO.	WALGREENS #17408	1015 BRIDGE RD	CHARLESTON	WV	25314-1305	04/16/2019	07/01/2019		07/01/2019
Contract Detail	WALGREEN CO.	WALGREENS #17781	2100 E DUPONT AVE	BELLE	WV	25015-1348	04/16/2019	07/01/2019	11/06/2023	11/15/2023
Contract Detail	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	10/15/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/11/2018	07/01/2018	10/13/2023	10/15/2023
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/11/2018	07/01/2018	10/13/2023	10/15/2023
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/11/2018	07/01/2018	10/13/2023	10/15/2023
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/11/2018	07/01/2018	10/01/2021	10/08/2021
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	01/16/2023	04/01/2023		04/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/15/2023	01/01/2024		01/01/2024
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07124	3901 TEAYS VALLEY RD.	HURRICANE	WV	25526	10/14/2020	01/01/2021		01/01/2021
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04207	4205 MACCORKLE AVE.	CHARLESTON	WV	25304	10/14/2020	01/01/2021		01/01/2021
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04244	121 10TH ST.	DUNBAR	WV	25064	10/14/2020	01/01/2021		01/01/2021
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04432	300 FOURTH AVE	MONTGOMERY	WV	25136	10/14/2020	01/01/2021		01/01/2021
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05957	221 CROSSINGS MALL ROAD	ELKVIEW	WV	25071	10/14/2020	01/01/2021		01/01/2021
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06306	201 MACCORKLE AVE.	SAINT ALBANS	WV	25177	10/14/2020	01/01/2021		01/01/2021
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	CVS/PHARMACY #10566	278 E MAIN STREET	MILTON	WV	25541	10/08/2021	01/01/2022		01/01/2022
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04167	700 NORTHSIDE DR.	SUMMERSVILLE	WV	26651	10/08/2021	01/01/2022		01/01/2022
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05946	72 WHITEWATER AVE.	FAYETTEVILLE	WV	25840	10/08/2021	01/01/2022		01/01/2022
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY #6311	11078 MIDLAND TRL	GAULEY BRIDGE	WV	25085	10/08/2021	01/01/2022	04/03/2024	04/03/2024
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY #2148	885 OAKWOOD ROAD	CHARLESTON	WV	25314	10/08/2021	01/01/2022		01/01/2022
Contract Detail	WEST VIRGINIA CVS PHARMACY, L.L.C.	CVS PHARMACY # 16609	30 RHL BLVD	SOUTH CHARLESTON	WV	25309	04/19/2023	07/01/2023		07/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH510022AA	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Nuclear Medicine	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022AB	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial MRI	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022AC	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Endoscopy	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022AD	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Family Medicine Center	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022AE	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial O/P Care Center	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022AF	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Recovery Room	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022AG	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Surgicenter	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022AH	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Women & Childrens Emergency Room	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AJ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Women & Childrens Delivery Room & Labor Room	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AK	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Women & Childrens Operating Room	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AL	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Women & Childrens Anesthesia	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AM	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Women & Childrens Recovery Room	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AN	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Women & Childrens Respiratory Care	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AP	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Women & Childrens Radiology	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AQ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Women & Childrens CT Scan	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AR	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Women & Childrens Nuclear Medicine	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AS	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Women & Childrens MRI	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AU	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Obstetrics and Gynecology Center (formerly WMC)	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AV	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	OP Imaging Center	3416 MacCorkle Ave. SE	Charleston	WV	Active
DSH510022AW	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Imaging Center-Southridge (Mountaineer Imaging)	60 R.H.L Blvd	South Charleston	WV	Active
DSH510022AX	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Post Cardiac Cath Unit	3200 MacCorkle Avenue SE	Charleston	WV	Terminated
DSH510022AY	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Women & Childrens Pediatrics Specialty Unit	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022AZ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Operating Room	1400 Hospital Drive	Hurricane	WV	Active
DSH510022B	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC MEMORIAL OBSERVATION BEDS	3200 MACCORKLE AVENUE SE	CHARLESTON	WV	Active
DSH510022BA	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Endoscopy	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BB	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Post Anesthesia Care Unit	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BC	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Radiology	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BD	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Radiology Ultrasound	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BE	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley MRI	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BF	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Mammography	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BG	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Nuclear Medicine	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BH	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley CT Scan	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BJ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Respiratory Care	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BK	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Physical Therapy	3948 Teays Valley Road	Hurricane	WV	Active
DSH510022BL	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Hyperbaric Chamber	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BM	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Cardiac Rehab	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BN	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Short Stay Surgery	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BP	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Ambulatory Infusion	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BQ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Emergency Room	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BR	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Doctor's Park Clinic	1206 Hospital Drive	Hurricane	WV	Active
DSH510022BS	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley TVH Vascular Center	3948 Teays Valley Road	Hurricane	WV	Active
DSH510022BT	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Anesthesia	1400 Hospital Drive	Hurricane	WV	Active
DSH510022BU	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	WEIGHT LOSS CENTER	Northgate Business Park	CHARLESTON	WV	Active
DSH510022BV	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Urology - Teays Valley	3948 Teays Valley Road	Hurricane	WV	Active
DSH510022BW	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Urology	1220 Lee Street, East	Charleston	WV	Active
DSH510022BX	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Urology - Memorial	3100 MacCorkle Avenue, S.E.	Charleston	WV	Active
DSH510022BY	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Pediatric Surgery	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022BZ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Pediatric Neurology	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022C	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC WOMEN & CHILDRENS OBSERVATION BEDS	800 PENNSYLVANIA AVENUE	CHARLESTON	WV	Active
DSH510022CA	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Pediatric ENT	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022CB	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Orthopedic Trauma	415 Morris St.	Charleston	WV	Active
DSH510022CC	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Orthopedic Surgery	3100 MacCorkle Ave, S.E.	Charleston	WV	Terminated
DSH510022CD	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Ophthalmology	1220 Lee St. East	Charleston	WV	Active
DSH510022CE	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Neurology - Teays Valley	3948 Teays Valley Road	Hurricane	WV	Active
DSH510022CF	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Neurology	415 Morris Street	Charleston	WV	Active
DSH510022CG	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Associated Cardiology - CAMC Cardiology	3100 MacCorkle Ave SE	Charleston	WV	Active
DSH510022CH	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Infectious Disease	3200 MacCorkle Avenue, S.E.	Charleston	WV	Active
DSH510022CJ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC General Surgery	3100 MacCorkle Ave, S.E.	Charleston	WV	Active
DSH510022CK	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC FACIAL SURGERY I	415 Morris Street	Charleston	WV	Active
DSH510022CL	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC FACIAL SURGERY II - CAMC Cleft & Craniofacial Center	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022CM	Child	DSH	CHARLESTON AREA MEDICAL CENTER INC.	CAMC Dental Center	3100 MacCorkle Ave SE	Charleston	WV	Terminated
DSH510022CN	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Cardiovascular Surgery	3100 MacCorkle Avenue, SE	Charleston	WV	Active
DSH510022CP	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Cancer Center Oncology	CAMC Cancer Center Oncology	Charleston	WV	Active
DSH510022CQ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC BARIATRIC SURGERY	600 Tracy Way	Charleston	WV	Terminated
DSH510022CR	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC CHARLESTON HEART SPECIALISTS	2335 CHESTERFIELD AVE	CHARLESTON	WV	Terminated
DSH510022CS	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC ASSOCIATED CARDIOLOGY	2930 CHESTERFIELD AVE	CHARLESTON	WV	Terminated
DSH510022CT	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Gastroenterology (GI) Clinic	3200 MacCorkle Avenue, S.E.	Charleston	WV	Terminated
DSH510022CU	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial / Clinical Decision Unit	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022CV	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Gynecology Oncology	3415 MacCorkle Ave., SE	Charleston	WV	Active
DSH510022CW	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC O/P Care Center / Ambulatory Care Clinic	3200 MacCorkle Ave SE	Charleston	WV	Terminated
DSH510022CX	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Cardiac Rehab / Cardiac Rehab	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022CY	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC / OB/GYN Clinic	830 Pennsylvania Ave	Charleston	WV	Active
DSH510022CZ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Physical Therapy Center/Sports Medicine	600 Tracy Way	Charleston	WV	Active
DSH510022DA	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Urologic Surgery - Courtney Drive	11 Courtney Drive	Charleston	WV	Active
DSH510022DB	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Primary Care - Winfield	12576 Winfield Rd.	Winfield	WV	Active
DSH510022DC	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Primary Care - Nitro	4111 First Avenue, Suite 3	Nitro	WV	Active
DSH510022DD	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Orthopedics Teays Valley	3948 Teays Valley Road	Hurricane	WV	Active
DSH510022DE	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Plastic Surgery	210 Brooks Street	Charleston	WV	Active
DSH510022DF	Child	DSH	CHARLESTON AREA MEDICAL CENTER INC.	CAMC Fertility Center (IVF - Lab)	830 Pennsylvania Avenue	Charleston	WV	Terminated
DSH510022DG	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Pediatric Clinic / Pediatric Service	800 Pennsylvania Avenue	Charleston	WV	Terminated
DSH510022DH	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Teays Valley Hospital / Observation Beds-Med/Surg	1400 Hospital Drive	Hurricane	WV	Active
DSH510022DJ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Cardiology - South Charleston - Cardiology - South Charleston	4610 Kanawha Ave, SW	South Charleston	WV	Active
DSH510022DK	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Primary Care - TV - CAMC Primary Care - TV	3248 Teays Valley Road	Hurricane	WV	Active
DSH510022DL	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	OP Surg Center - Gen - OP Surg Center - Gen	1220 Lee St. East	Charleston	WV	Active
DSH510022DM	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Surgery - TV - General Surgery	3948 Teays Valley Road	Hurricane	WV	Active
DSH510022DN	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Electrophysiology - CAMC Electrophysiology	3100 MacCorkle Avenue, SE	Charleston	WV	Active
DSH510022DP	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Stroke Center - Occupational Health and Wellness WCH	800 Pennsylvania Avenue	Charleston	WV	Terminated
DSH510022DQ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Occupational Health and Wellness MEM - Occupational Health and Wellness MEM	3100 MacCorkle Avenue, SE	Charleston	WV	Terminated
DSH510022DR	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Occupational Health and Wellness TVH - Occupational Health and Wellness TVH	1400 Hospital Drive	Hurricane	WV	Terminated
DSH510022DS	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Rheumatology - CAMC Rheumatology	4610 Kanawha Ave SW	South Charleston	WV	Terminated
DSH510022DT	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PERINATAL DIAG CTR CLINIC WCH - Women & Childrens Perinatal Diagnostic Center	800 PENNSYLVANIA AVE	CHARLESTON	WV	Active
DSH510022DU	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Non-Invasive Vascular Clinic - Teays Valley Non-Invasive Vascular Lab	1400 Hospital Drive	Hurricane	WV	Active
DSH510022DV	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC EMPLOYEE WELLNESS CENTER - Employee Wellness Center	3418 STAUNTON AVE SE	CHARLESTON	WV	Active
DSH510022DW	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Electrocardiology - CAMC Memorial EKG	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022DX	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Electrocardiology - CAMC Women & Childrens EKG	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022DY	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Nuclear Med/Cobalt - Memorial Radiation Therapy	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022DZ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Electroencephalography - CAMC Women & Childrens Neurodiagnostics EEG	800 Pennsylvania Ave	Charleston	WV	Active
DSH510022E	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC INFUSION SERVICES	3415 MacCorkle Ave SE	CHARLESTON	WV	Active
DSH510022EA	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Pulmonary Function Testing - CAMC Memorial Perfusion	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022EB	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Laboratory - CAMC Memorial Laboratory	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022EC	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Radiology - Diagnostic - CAMC Memorial Radiology Ultrasound	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022ED	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Blood Storing, Processing, & Trans. - CAMC Memorial Transfusion Services	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022EE	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Radiology - Diagnostic - Women & Childrens OB Ultrasound	800 Pennsylvania Ave	Charleston	WV	Active
DSH510022EF	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Electroencephalography - CAMC Memorial Neurodiagnostics EEG	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022EG	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Laboratory - Teays Valley Laboratory	1400 Hospital Drive	Hurricane	WV	Active
DSH510022EH	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Electroencephalography - Teays Valley Echocardiogram	1400 Hospital Drive	Hurricane	WV	Active
DSH510022EJ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Radiology - Diagnostic - Teays Valley CDL Lab	1400 Hospital Drive	Hurricane	WV	Active
DSH510022EK	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Laboratory - CAMC Memorial Lab Microbiology	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022EL	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC INFECTIOUS DISEASE - CAMC Infectious Disease MSOB	3100 MACCORKLE AVE SE	CHARLESTON	WV	Active
DSH510022EM	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - Pediatric Pulmonology	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022EN	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	G.I. - CAMC Gastroenterology	2930 Chesterfield Avenue	Charleston	WV	Active
DSH510022EP	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Physical Therapy - WCH	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022EQ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - Pediatric Rheumatology	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022ER	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Internal Med - Internal Medicine Office	3100 MacCorkle Ave. SE	Charleston	WV	Active
DSH510022ES	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - Pediatric Endocrinology	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022ET	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	TELEMEDICINE - 24/7 Cares	415 Morris Street	Charleston	WV	Active
DSH510022EU	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - Pediatric Cardiology	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022EV	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - Pediatric Develop & Behavior	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022EW	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC CARDIOLOGY - TEAYS VALLEY - Cardiology Teays Valley	3948 Teays Valley Road	HURRICANE	WV	Active
DSH510022EX	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Endocrinology - Endocrinology Clinic	3100 MacCorkle Ave. SE	Charleston	WV	Active
DSH510022EY	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - Pediatric Gastroenterology	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022EZ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PRIMARY CARE CHARLESTON - Primary Care Charleston	3411 Noyes Ave	CHARLESTON	WV	Active
DSH510022F	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC HEMOPHILIA TREATMENT CENTER	3200 MACCORKLE AVE SE	CHARLESTON	WV	Active
DSH510022FA	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC KIDNEY ACQUISITION - CAMC Kidney Transplant Clinic	415 Morris Street	Charleston	WV	Active
DSH510022FB	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - Pediatric Infectious Disease	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022FC	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Rheumatology Clinic - CAMC Rheumatology	3100 MacCorkle Ave. SE	Charleston	WV	Active
DSH510022FD	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Physical Therapy - Memorial	3200 MacCorkle Ave. SE	Charleston	WV	Active
DSH510022FE	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	OPERATING ROOM - Patient AM Admission - Memorial PAC	3200 MacCorkle Ave. SE	Charleston	WV	Active
DSH510022FF	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - Hematology & Onc	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022FG	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PED DEPARTMENTS - CF Center	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022FH	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Recovery Room - Patient Access Center- WCH	800 Pennsylvania Avenue	Charleston	WV	Active
DSH510022FJ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PULMONOLOGY - Pulmonology MSOB	3100 MACCORKLE AVE SE	CHARLESTON	WV	Active
DSH510022FK	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Behavioral Medicine Center - Behavioral Medicine Center	3200 MacCorkle Avenue	Charleston	WV	Active
DSH510022FL	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Trauma Surgery - Trauma Surgery	1220 Lee Street	Charleston	WV	Active
DSH510022FM	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Pediatric Nephrology - CAMC Pediatric Nephrology	830 Pennsylvania Avenue	Charleston	WV	Active
DSH510022FN	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Ryan White Program - CAMC ID	3200 MacCorkle Avenue	Charleston	WV	Active
DSH510022FP	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	OB/GYN TV - OB GYN Teays	1401 Hospital Drive	Hurricane	WV	Active
DSH510022FQ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Rheumatology - CAMC Rheumatology TV	1401 Hospital Drive	Hurricane	WV	Active
DSH510022FR	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Pulmonary TV - CAMC Pulmonary Teays Valley	1401 Hospital Drive	Hurricane	WV	Active
DSH510022FS	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Mobile Clinic - Mobile Clinic	3200 MacCorkle Avenue	Charleston	WV	Active
DSH510022FT	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC GI TV - G.I. Teays Valley	3948 Teays Valley Road	Hurricane	WV	Active
DSH510022FU	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Cardiac Rehab SC - CAMC Cardiopulm Rehab SC	4610 Kanawha Avenue SW	South Charleston	WV	Active
DSH510022FV	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Rheumatology - Rheumatology South Charleston	4610 Kanawha Avenue SW	South Charleston	WV	Active
DSH510022FW	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	General Surgery Clinic - CAMC General Surgery	3100 MacCorkle Avenue	Charleston	WV	Active
DSH510022FX	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC NEPHROLOGY - Nephrology	2345 CHESTERFIELD AVE	CHARLESTON	WV	Active
DSH510022FY	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Telemedicine Hubs - Telemedicine Pocahontas	150 Duncan Road	Buckeye	WV	Active
DSH510022FZ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Telemedicine Hubs - Telemedicine Princeton	150 Courthouse Road	Princeton	WV	Active
DSH510022G	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC URGENT CARE	314 GOFF MOUNTAIN ROAD	CROSS LANES	WV	Active
DSH510022GA	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC SLEEP CENTER RIPLEY - Ohio Valley Sleep Center	300 CLAY LICK RD	RIPLEY	WV	Active
DSH510022GB	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PEDIATRIC SPECIALISTS TV - Pediatric GI - Teays Valley	3948 TEAYS VALLEY RD	HURRICANE	WV	Active
DSH510022GC	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC CANCER & INFUSION CENTER TV - Cancer Center Teays	1401 Hospital Drive	HURRICANE	WV	Active
DSH510022GD	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Interventional Radiology - Interventional Radiology	3200 MacCorkle Avenue	Charleston	WV	Active
DSH510022GE	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PRIMARY CARE POCA - Primary Care Poca	2851 CHARLESTON RD	POCA	WV	Active
DSH510022GF	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC THORACIC & ESOPHAGEAL SURGERY - Thoracic Surgery	3100 MACCORKLE AVE SE	CHARLESTON	WV	Active
DSH510022GG	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	Rural Health Clinic - Primary Care Summersville	702 Professional Park Drive	Summersville	WV	Active
DSH510022GH	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Ryan White Clinic - Beckley - Ryan White Clinic - Beckley	1838 Harper Rd	Beckley	WV	Active
DSH510022GJ	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC PEDIATRIC SPECIALISTS TV - Pediatric Pulmonology - TV	3948 TEAYS VALLEY RD	HURRICANE	WV	Active
DSH510022GK	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC CANCER CENTER - BECKLEY - Beckley Cancer	275 DRY HILL RD	BECKLEY	WV	Active
DSH510022H	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC WOUND HEALING CENTER	600 MORRIS STREET	CHARLESTON	WV	Active
DSH510022J	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Breast Center	3415 MacCorkle Ave SE	Charleston	WV	Active
DSH510022K	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Emergency Room	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022L	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Operating Room	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022M	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Anesthesia	3200 MacCorkle Ave SE	Charleston	WV	Active
DSH510022N	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Cardiac Cath Lab	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022P	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Non Invasive Vascular Lab	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022Q	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Vascular Center of Excellence	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022R	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Lab CDL	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022S	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Pulmonary Function	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022T	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Pulmonary Rehab	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022U	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Cancer Services	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022V	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Ambulatory Infusion Center	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022W	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Respiratory Care	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022X	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial Radiology	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022Y	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial CT Scan	3200 MacCorkle Avenue SE	Charleston	WV	Active
DSH510022Z	Child	DSH	CHARLESTON AREA MEDICAL CENTER (CAMC)	CAMC Memorial CT Scan Cardiology	3200 MacCorkle Avenue SE	Charleston	WV	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Change Request		1265421226	3/16/2025 8:21 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/16/2025 8:21 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1487439683	3/16/2025 8:21 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/16/2025 8:21 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1518579689	3/16/2025 8:21 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/16/2025 8:21 PM
Contacts	Primary Contact	Update	Profile Change Request	Sayre, Brian Chief Pharmacy Officer Charleston Area Medical Center 3043888917	Sayre, Brian VP of Pharmacy Services Vandalia Health 3043888917	1/6/2025 10:50 AM
Addresses	Shipping Address	Insert	Change Request		CAMC Pharmacy South Charleston 4610 Kanawha Ave. SW South Charleston, WV 25309	11/26/2024 2:25 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0001342000 (WV)		10/31/2024 3:29 PM
Details	Last Recertification Date	Update	Recertification	8/26/2023 3:26:04 PM	8/22/2024 11:27:56 AM	8/22/2024 11:27 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (ME)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	010695000 (MD)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	7006632 (MA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0268688 (OH)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0169024700 (KY)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	CHA0022N (AL)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	CAM0022N (AL)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	CMH0022N (AL)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1571130 (AK)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	28763 (AZ)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	115076105 (AR)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (CA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	95510020 (CO)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	003036340 (CT)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (DE)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	037201900 (DC)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	037201901 (DC)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	909271400 (FL)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	090122900 (FL)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000209547X (GA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	001904000 (ID)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100038360 (IN)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	550526150-001 (IL)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	979500 (IA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100105550A (KS)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1744069 (LA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (MI)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (MN)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00095554 (MS)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	09585249 (MS)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (MT)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10024976201 (NE)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10024979000 (NE)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	20002375 (NH)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	4232003 (NJ)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	67105505 (NM)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (NY)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	5100022 (NC)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	550523150-03 (OH)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100696050 (OK)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	291083 (OR)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00913204-0004 (PA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	139868 (SC)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	255935 (SC)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (SD)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0510022 (TN)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0729576-01 (TX)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (UT)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	009815678 (VA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (VA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0089461 (WA)		6/28/2024 12:28 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1952390239 (WI)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (AK)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (AL)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (AR)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (AZ)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (CA)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (CO)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (CT)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (DC)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (DE)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (FL)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (GA)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (IA)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (ID)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (IL)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (IN)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (WI)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (WA)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (VA)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (UT)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (TX)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (TN)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (SD)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (SC)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (PA)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (OR)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (OK)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (OH)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (KS)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (KY)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (NY)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (NM)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (NJ)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (NH)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (NE)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (NC)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (MT)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (MS)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (MN)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (MI)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (ME)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (MD)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (MA)		6/28/2024 12:28 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1952390239 (LA)		6/28/2024 12:28 PM
Contacts	Primary Contact	Update	Profile Change Request	Sayre, Brian Health System Director of Pharmacy Charleston Area Medical Center 3043888917	Sayre, Brian Chief Pharmacy Officer Charleston Area Medical Center 3043888917	6/28/2024 10:34 AM
Addresses	Shipping Address	Insert	Change Request		CAMC Pharmacy #5 400 Association Drive Charleston, WV 25311-1295	3/25/2024 6:25 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1427627058	2/9/2024 10:02 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	2/9/2024 10:02 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 2:18:01 PM	8/26/2023 3:26:04 PM	8/26/2023 3:26 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		AK	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		AL	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		AR	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		CA	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		CT	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		DC	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		DE	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		GA	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		ID	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		WI	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		WA	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		VA	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		UT	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		TX	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		TN	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		SD	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		SC	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		OR	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		OK	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		KS	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		KY	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		NY	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		NM	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		NH	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		NE	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		NC	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		MT	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		MS	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		MD	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		MA	2/28/2023 8:38 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952390239	2/28/2023 8:38 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	2/28/2023 8:38 PM
Addresses	Shipping Address	Insert	Change Request		Safecor Health, LLC. 317 New Boston Street Woburn, MA 01801	2/13/2023 1:57 PM
Addresses	Shipping Address	Insert	Change Request		CAMC Pharmacy #4 3948 Teays Valley Road Hurricane, WV 25526	2/13/2023 1:57 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 2:42:40 PM	8/26/2022 2:18:01 PM	8/26/2022 2:18 PM
Contacts	Authorizing Official	Update	AO Change Request	BELL, STEPHEN VICE PRESIDENT - FINANCE Charleston Area Medical Center 3043886251	Sandene, Jeff D EVP CFO CAMC Health System 3043887603	6/30/2022 2:29 PM
Addresses	Shipping Address	Delete	Change Request	CAMC Pharmacy #4 4619 Kanawha Ave SW South Charleston, WV 25309		5/3/2022 7:42 AM
Addresses	Shipping Address	Insert	Change Request		CAMC Pharmacy #4 4619 Kanawha Ave SW South Charleston, WV 25309	9/17/2021 3:28 PM
Details	Last Recertification Date	Update	Recertification	9/11/2020 8:36:15 AM	9/9/2021 2:42:40 PM	9/9/2021 2:42 PM
Addresses	Billing Address	Insert	Change Request		CAMC Accounts Payable PO Box 2069 Charleston, WV 25301	1/29/2021 9:18 AM
Addresses	Shipping Address	Insert	Change Request		CAMC Pharmacy #2 501 Morris St. Charleston, WV 25301	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010695000	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7006632	1/29/2021 9:18 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	1/29/2021 9:18 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1588875595	1/29/2021 9:18 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	1/29/2021 9:18 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1124248752	1/29/2021 9:18 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	1/29/2021 9:18 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1134517394 (WV)		1/29/2021 9:18 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1265421226 (WV)		1/29/2021 9:18 AM
Contacts	Primary Contact	Update	Profile Change Request	Sayre, Brian Health System Director of Pharmacy Charelston Area Medical Center 3043888917	Sayre, Brian Health System Director of Pharmacy Charleston Area Medical Center 3043888917	1/27/2021 2:57 PM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Medicaid Billing	NPI: State	Update	Recertification		WV	9/11/2020 8:36 AM
Details	Last Recertification Date	Update	Recertification	9/6/2019 11:29:04 AM	9/11/2020 8:36:15 AM	9/11/2020 8:36 AM
Details	Last Recertification Date	Update	Recertification	8/29/2018 9:10:07 AM	9/6/2019 11:29:04 AM	9/6/2019 11:29 AM
Details	Last Recertification Date	Update	Recertification	11/16/2017 10:53:59 AM	8/29/2018 9:10:07 AM	8/29/2018 9:10 AM
Addresses	Shipping Address	Delete	Change Request	CAMC Pharmacy #2 314 Goff Mountain Road Suite 5 Cross Lanes, WV 25313		6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		CHA0022N	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		CAM0022N	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		CMH0022N	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AL	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1571130	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AK	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		28763	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		115076105	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		95510020	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003036340	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DE	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		037201900	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DC	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		037201901	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DC	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		909271400	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		090122900	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000209547X	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		001904000	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ID	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100038360	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		550526150-001	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		979500	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100105550A	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KS	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1744069	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00095554	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		09585249	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MT	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10024976201	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10024979000	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		20002375	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NH	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4232003	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		67105505	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		5100022	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		550523150-03	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100696050	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		291083	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OR	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00913204-0004	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		139868	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		255935	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SD	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0510022	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0729576-01	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		UT	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		009815678	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0089461	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WA	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1952390239	6/29/2018 8:15 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	6/29/2018 8:15 AM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/16/2017 10:53:59 AM	11/16/2017 10:53 AM
Contacts	Authorizing Official	Update		BELL, STEPHEN VICE PRESIDENT - FINANCE 3043886251	BELL, STEPHEN VICE PRESIDENT - FINANCE Charleston Area Medical Center 3043886251	10/20/2017 1:16 PM
Contacts	Primary Contact	Update		Sayre, Brian Health System Director of Pharmacy 3043888917	Sayre, Brian Health System Director of Pharmacy Charelston Area Medical Center 3043888917	10/9/2017 9:55 AM
Contacts	Authorizing Official	Update		ARTHUR III, CLENNIE E. EXECUTIVE VICE PRESIDENT AND CFO 3043885390	BELL, STEPHEN VICE PRESIDENT - FINANCE 3043886251	7/28/2017 6:19 PM
Contacts	Primary Contact	Insert			Sayre, Brian Health System Director of Pharmacy 3043888917	7/28/2017 6:19 PM
Addresses	Main Address	Insert			501 MORRIS STREET CHARLESTON, WV 25301	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC SOLUTIONS 2568 PENNSYLVANIA AVENUE CHARLESTON, WV 25302	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC General Pharmacy 501 Morris Street Charleston, WV 25301	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC Pharmacy 3200 MacCorkle Ave SE Charleston, WV 25304	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC Women & Childrens Pharmacy 800 Pennsylvania Avenue Charleston, WV 25302	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC Memorial Pharmacy 3200 MacCorkle Avenue SE Charleston, WV 25304	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC Pharmacy #2 314 Goff Mountain Road Suite 5 Cross Lanes, WV 25313	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC Oncology Pharmacy Services 3415 MacCorkle Ave SE Charleston, WV 25304	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC Nuclear Pharmacy 3200 MacCorkle Ave SE Charleston, WV 25304	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			Safecor Health, LLC 4060 Business Park Drive, Suite B Columbus, OH 43204	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC Pharmacy #3 3415 MacCorkle Ave SE Charleston, WV 25304	7/28/2017 6:19 PM
Addresses	Shipping Address	Insert			CAMC Teays Valley Pharmacy 1400 Hospital Drive Hurricane, WV 25526	7/28/2017 6:19 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/2/2016 9:05 AM
Medicaid Billing	Medicaid: Number	Insert			0268688	12/2/2016 9:05 AM
Medicaid Billing	Medicaid: State	Insert			OH	12/2/2016 9:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	12/2/2016 9:05 AM
Medicaid Billing	Medicaid: Number	Insert			0169024700	12/2/2016 9:05 AM
Medicaid Billing	Medicaid: State	Insert			KY	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1952390239	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1326253592	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1427270586	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1396965927	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1316101819	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1073529616	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1245544527	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1053693697	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1033482443	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1205978509	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1912247750	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1134518186	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1134517394	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1639168693	12/2/2016 9:05 AM
Medicaid Billing	NPI: Number	Insert			1265421226	12/2/2016 9:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/18/2016 9:41 AM
Medicaid Billing	Medicaid: Number	Insert			0001342000	8/18/2016 9:41 AM
Medicaid Billing	Medicaid: State	Insert			WV	8/18/2016 9:41 AM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 9:41 AM
Details	Last Recertification Date	Update		8/22/2014 12:00:00 AM	9/2/2015 12:00:00 AM	9/2/2015 10:30 AM
Details	Last Recertification Date	Update		9/9/2013 12:00:00 AM	8/22/2014 12:00:00 AM	8/22/2014 8:26 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/9/2013 12:00:00 AM	9/9/2013 9:50 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/18/2012 12:07 PM
Contacts	Authorizing Official	Insert			ARTHUR III, CLENNIE E. EXECUTIVE VICE PRESIDENT AND CFO 3043885390	1/21/2011 1:02 PM
Details	Last Recertification Date	Insert				1/21/2011 1:02 PM
Details	Grant Number	Insert				1/21/2011 1:02 PM
Details	340B ID	Insert			DSH510022	1/21/2011 1:02 PM
Details	Is Authorizing Official EHB Data	Insert				1/21/2011 1:02 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/21/2011 1:02 PM
Details	Medicare Provider Number	Insert			510022	1/21/2011 1:02 PM
Details	Entity Name	Insert			CHARLESTON AREA MEDICAL CENTER (CAMC)	1/21/2011 1:02 PM
Details	Program Code	Insert			DSH	1/21/2011 1:02 PM
Details	Entity Subname	Insert				1/21/2011 1:02 PM
Dates	Participating Approval Date	Insert			7/8/2008 12:00:00 AM	1/21/2011 1:02 PM
Details	State	Insert			Active	1/21/2011 1:02 PM
Dates	Registration Date	Insert			7/8/2008 12:00:00 AM	1/21/2011 1:02 PM
Dates	Signed By Date	Insert			3/22/2005 12:00:00 AM	1/21/2011 1:02 PM
Dates	Start Date	Insert			9/22/2005 12:00:00 AM	1/21/2011 1:02 PM
Terminations	Termination Comments	Insert				1/21/2011 1:02 PM
Terminations	Termination Date	Insert				1/21/2011 1:02 PM
Terminations	Termination Effective Date	Insert				1/21/2011 1:02 PM
Terminations	Termination Reason	Insert				1/21/2011 1:02 PM
Details	Comments Public	Insert			1/21/2011- ADDED SHIP TO; ORIG PART 7/1/03-6/30/05, NOT ELIG 7/1/05-9/21/05	1/21/2011 1:02 PM