Covered Entity Details

DSH220035 NORTH SHORE MEDICAL CENTER (Active) - information as of 5/20/2025 11:35:04 PM

Main Details

Name

NORTH SHORE MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220035

Medicare Provider Number

220035

Additional Details

Current Program Status

Active

Registration Date

9/5/2008

Participating Start Date

9/5/2008

Participating Approval Date

9/5/2008

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

North Shore Medical Center
Charles E Adams, Executive Director, Finance
(978) 354-4000

Primary Contact

Mass General Brigham - Boston, MA
Rafic Nehme, Enterprise Director
(617) 726-5125

Addresses

Street Address

81 HIGHLAND AVENUE
SALEM, MA 01970

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
6/8/2010-DOC RECD TO CONFIRM ELIG DSH ADJ % 9/1/09 - DOC RECD TO CONFIRM ELIG DSH ADJ %	09/05/2008

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
MA	110026758B	1730121633

Shipping Addresses

Shipping Address 1

Safecor Health
317 New Boston St.
Suite 100
Woburn, MA 01801

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	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/12/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/12/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/12/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/12/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/12/2023	01/01/2024		01/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	10/12/2023	01/01/2024		01/01/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	6 SPRING MILL DR	MALVERN	PA	19355	01/14/2025	04/01/2025		04/01/2025
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	2345 WATERS DRIVE	MENDOTA HEIGHTS	MN	55120	01/14/2025	04/01/2025		04/01/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	11/18/2022	11/18/2022		11/18/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	11/18/2022	11/18/2022		11/18/2022
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00261	200 ESSEX STREET	SALEM	MA	01970	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00314	45 ATLANTIC AVENUE	MARBLEHEAD	MA	01945	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00457	426B ESSEX ST	SALEM	MA	01970	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00669	413 PARADISE RD STE A	SWAMPSCOTT	MA	01907	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00751	434 RANTOUL ST.	BEVERLY	MA	01915	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01025	272 HIGHLAND AVE.	SALEM	MA	01970	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 02533	79 LYNNFIELD STREET	PEABODY	MA	01960	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 02959	139 ENDICOTT ST.	DANVERS	MA	01923	03/08/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 04073	174 MAIN ST.	PEABODY	MA	01960	03/31/2013	04/01/2013	11/04/2016	11/09/2016
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00073	5 MACY STREET	AMESBURY	MA	01913	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00075	200 SOUTH COMMON ST.	LYNN	MA	01905	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00314	45 ATLANTIC AVENUE	MARBLEHEAD	MA	01945	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00318	637 LOWELL ST.	PEABODY	MA	01960	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00457	426B ESSEX ST	SALEM	MA	01970	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00669	413 PARADISE RD STE A	SWAMPSCOTT	MA	01907	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00751	434 RANTOUL ST.	BEVERLY	MA	01915	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00915	19 DODGE ST STE A	BEVERLY	MA	01915	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01011	311 NEWBURY ST.	DANVERS	MA	01923	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01025	272 HIGHLAND AVE.	SALEM	MA	01970	10/11/2022	01/01/2023	01/01/2025	01/14/2025
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01132	13-1/2 POND STREET	NEWBURYPORT	MA	01950	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01181	1 MAPLE STREET	DANVERS	MA	01923	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01204	509 EASTERN AVENUE	LYNN	MA	01902	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 02533	79 LYNNFIELD STREET	PEABODY	MA	01960	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 02959	139 ENDICOTT ST.	DANVERS	MA	01923	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 04073	174 MAIN ST.	PEABODY	MA	01960	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 05939	242 CAMBRIDGE ST.	BURLINGTON	MA	01803	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA CVS/PHARMACY # 7109	300 CANAL STREET	SALEM	MA	01970	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	CVS/PHARMACY #10502	75 STOREY AVE.	NEWBURYPORT	MA	01950	10/11/2022	01/01/2023		01/01/2023
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 02177	65 CENTRAL STREET	GEORGETOWN	MA	01833	07/02/2024	10/01/2024		10/01/2024
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 02500	1075 BROADWAY ST.	SAUGUS	MA	01906	07/02/2024	10/01/2024		10/01/2024
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 00272	401 GLOUCESTER CROSSING RD.	GLOUCESTER	MA	01930	01/14/2025	04/01/2025		04/01/2025
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/11/2022	01/01/2023		01/01/2023
Contract Detail	D.A.W., LLC	D/B/A CVS/PHARMACY # 11265	270 UNION STREET	LYNN	MA	01901	10/11/2022	01/01/2023	04/01/2024	07/02/2024
Contract Detail	MASS GENERAL BRIGHAM SPECIALTY PHARMACY,	ATTN: PHARMACY	31 NORTH AVE	BURLINGTON	MA	01803	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	20 COMMERCE WAY	SUITE 2	WOBURN	MA	01801	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	07/11/2024	10/01/2024		10/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	10/12/2023	01/01/2024		01/01/2024
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/12/2023	01/01/2024		01/01/2024
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/11/2022	01/01/2023		01/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 2516	35 KNEELAND STREET	BOSTON	MA	02111	10/11/2022	01/01/2023		01/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2971	350 LONGWOOD AVE., STE B	BOSTON	MA	02115	10/11/2022	01/01/2023		01/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/11/2022	01/01/2023		01/01/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/11/2022	01/01/2023		01/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH220035AA	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - SLM Cardiovasc LMV	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035AB	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - Salem Hospital Endoscopy at Lynn Medical Village	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035AC	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - Salem Hospital Primary Care at Lynn Medical Village	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035AD	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - Salem Hospital Nephrology at Lynn Medical Village	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035AE	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - Salem Hospital Nutrition at Lynn Medical Village	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035B	Child	DSH	NORTH SHORE MEDICAL CENTER	Union Hospital	500 LYNNFIELD STREET	LYNN	MA	Terminated
DSH220035C	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Angio Interv XRay	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035D	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Center for Pre-Op Evaluation	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035E	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Cardiac Rehabilitation	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035F	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Pain Clinic	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035G	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Pulmonary Rehabilitation	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035H	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Infusion Clinic	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035J	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Nuclear Cardiology	500 Lynnfield Street, South 1	Lynn	MA	Terminated
DSH220035K	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Respiratory Care/PFT	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035L	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union IV Therapy	500 Lynnfield Street, 2nd Floor	Lynn	MA	Terminated
DSH220035M	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union CT Scan	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035N	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Radioisotope	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035P	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Radiology / Diagnostic	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035Q	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Anesthesiology	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035R	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Recovery Room	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035S	Child	DSH	NORTH SHORE MEDICAL CENTER	North Shore Medical Center Union Hospital / Union Operating Room	500 Lynnfield Street	Lynn	MA	Terminated
DSH220035T	Child	DSH	NORTH SHORE MEDICAL CENTER	Union Hospital Emergency Room / Union Hospital Emergency Room	500 Lynnfield Street, Ground Floor	Lynn	MA	Terminated
DSH220035U	Child	DSH	NORTH SHORE MEDICAL CENTER	NSMC Outpatient Mental Health at Union Hospital / MH Hartman Hall Clinic	490 Lynnfield Street	Lynn	MA	Terminated
DSH220035V	Child	DSH	NORTH SHORE MEDICAL CENTER	NSMC Professional Services / MH Highland Hall Clinic	55 Highland Avenue	Salem	MA	Active
DSH220035W	Child	DSH	NORTH SHORE MEDICAL CENTER	NSMC MRI Centennial	4 Centennial Dr Suite# 104	Peabody	MA	Active
DSH220035X	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER I - SLM OP MH CLINIC LMV	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035Y	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - SLM Rheum LMV	480 LYNNFIELD ST	LYNN	MA	Active
DSH220035Z	Child	DSH	NORTH SHORE MEDICAL CENTER	NORTH SHORE MEDICAL CENTER, INC - SLM Pulm LMV	480 LYNNFIELD ST	LYNN	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	McHatton, Ralph Michael Director Pharmacy North Shore Medical Center 9783542358	Nehme, Rafic Enterprise Director Mass General Brigham - Boston, MA 6177265125	9/4/2024 3:06 PM
Details	Last Recertification Date	Update	Recertification	9/6/2023 1:04:15 PM	9/4/2024 3:06:20 PM	9/4/2024 3:06 PM
Details	Last Recertification Date	Update	Recertification	9/9/2022 6:58:02 AM	9/6/2023 1:04:15 PM	9/6/2023 1:04 PM
Details	Last Recertification Date	Update	Recertification	8/26/2021 7:13:21 AM	9/9/2022 6:58:02 AM	9/9/2022 6:58 AM
Details	Last Recertification Date	Update	Recertification	9/5/2020 12:02:20 AM	8/26/2021 7:13:21 AM	8/26/2021 7:13 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1730121633	9/5/2020 12:02 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/5/2020 12:02 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1730121633 ( )		9/5/2020 12:02 AM
Details	Last Recertification Date	Update	Recertification	9/15/2019 8:21:34 AM	9/5/2020 12:02:20 AM	9/5/2020 12:02 AM
Details	Last Recertification Date	Update	Recertification	9/11/2018 1:21:49 PM	9/15/2019 8:21:34 AM	9/15/2019 8:21 AM
Addresses	Shipping Address	Insert	Change Request		Safecor Health 317 New Boston St. Suite 100 Woburn, MA 01801	9/5/2019 10:34 AM
Details	Last Recertification Date	Update	Recertification	11/15/2017 9:42:22 PM	9/11/2018 1:21:49 PM	9/11/2018 1:21 PM
Medicaid Billing	Medicaid: Number	Update	Recertification	110026758b	110026758B	11/15/2017 9:42 PM
Details	Last Recertification Date	Update	Recertification	8/26/2016 12:00:00 AM	11/15/2017 9:42:22 PM	11/15/2017 9:42 PM
Contacts	Authorizing Official	Update		Boemer, Sally Mason Senior Vice President of Finance 6177244537	Boemer, Sally Mason Senior Vice President of Finance Mass General Hospital 6177244537	10/12/2017 1:06 PM
Contacts	Primary Contact	Update		McHatton, Ralph Director Pharmacy 9783542358	McHatton, Ralph Michael Director Pharmacy North Shore Medical Center 9783542358	10/11/2017 5:31 PM
Contacts	Authorizing Official	Update	AO Change Request	Boemer, Sally Mason Senior Vice President of Finance Mass General Hospital 6177244537	Adams, Charles E Executive Director, Finance North Shore Medical Center 9783544000	10/3/2017 2:50 PM
Contacts	Authorizing Official	Update		WISEMAN, ROGER D. CFO 9788256200	Boemer, Sally Mason Senior Vice President of Finance 6177244537	8/8/2017 8:30 AM
Contacts	Primary Contact	Update		WISEMAN, ROGER D. CFO 9788256200	McHatton, Ralph Director Pharmacy 9783542358	8/1/2017 2:45 PM
Addresses	Main Address	Insert			81 HIGHLAND AVENUE SALEM, MA 01970	7/17/2017 12:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/17/2017 12:00 PM
Medicaid Billing	Medicaid: Number	Insert			110026758b	7/17/2017 12:00 PM
Medicaid Billing	Medicaid: State	Insert			MA	7/17/2017 12:00 PM
Medicaid Billing	NPI: Number	Insert			1730121633	7/17/2017 12:00 PM
Details	Last Recertification Date	Update		8/28/2015 12:00:00 AM	8/26/2016 12:00:00 AM	8/26/2016 1:56 PM
Details	Last Recertification Date	Update		9/4/2014 12:00:00 AM	8/28/2015 12:00:00 AM	8/28/2015 1:14 PM
Details	Last Recertification Date	Update		8/21/2013 12:00:00 AM	9/4/2014 12:00:00 AM	9/4/2014 2:27 PM
Contacts	Authorizing Official	Insert			WISEMAN, ROGER D. CFO 9788256200	7/3/2014 4:20 PM
Contacts	Primary Contact	Insert			WISEMAN, ROGER D. CFO 9788256200	7/3/2014 4:20 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/21/2013 12:00:00 AM	8/21/2013 2:19 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/29/2012 12:30 PM
Details	Last Recertification Date	Insert				9/5/2008 1:27 PM
Details	Grant Number	Insert				9/5/2008 1:27 PM
Details	340B ID	Insert			DSH220035	9/5/2008 1:27 PM
Details	Is Authorizing Official EHB Data	Insert				9/5/2008 1:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/5/2008 1:27 PM
Details	Medicare Provider Number	Insert			220035	9/5/2008 1:27 PM
Details	Entity Name	Insert			NORTH SHORE MEDICAL CENTER	9/5/2008 1:27 PM
Details	Program Code	Insert			DSH	9/5/2008 1:27 PM
Details	Entity Subname	Insert				9/5/2008 1:27 PM
Dates	Participating Approval Date	Insert			9/5/2008 12:00:00 AM	9/5/2008 1:27 PM
Details	State	Insert			Active	9/5/2008 1:27 PM
Dates	Registration Date	Insert			9/5/2008 12:00:00 AM	9/5/2008 1:27 PM
Dates	Signed By Date	Insert			8/28/2008 12:00:00 AM	9/5/2008 1:27 PM
Dates	Start Date	Insert			9/5/2008 12:00:00 AM	9/5/2008 1:27 PM
Terminations	Termination Comments	Insert				9/5/2008 1:27 PM
Terminations	Termination Date	Insert				9/5/2008 1:27 PM
Terminations	Termination Effective Date	Insert				9/5/2008 1:27 PM
Terminations	Termination Reason	Insert				9/5/2008 1:27 PM
Details	Comments Public	Insert			6/8/2010-DOC RECD TO CONFIRM ELIG DSH ADJ % 9/1/09 - DOC RECD TO CONFIRM ELIG DSH ADJ %	9/5/2008 1:27 PM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

Parent/Child

History