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| Contract Detail | BATTS DRUG CO | 115 COMMERCE ST |
| HAWKINSVILLE | GA | 31036 | 04/10/2012 | 04/10/2012 | | 09/10/2019 | 09/10/2019 |
| Details | Last Recertification Date | Update | Recertification | 9/7/2023 7:54:16 AM | 9/6/2024 2:20:20 PM | 9/6/2024 2:20 PM |
| Details | Last Recertification Date | Update | Recertification | 9/7/2022 9:33:31 AM | 9/7/2023 7:54:16 AM | 9/7/2023 7:54 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Roland, John
COO
Bleckley Memorial Hospital
4789346211-590 | Roland, John
COO
Bleckley Memorial Hospital
4789346211-1304 | 9/6/2023 9:16 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2021 1:31:40 PM | 9/7/2022 9:33:31 AM | 9/7/2022 9:33 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2020 1:42:41 PM | 8/27/2021 1:31:40 PM | 8/27/2021 1:31 PM |
| Details | Last Recertification Date | Update | Recertification | 9/11/2019 7:44:10 AM | 8/24/2020 1:42:41 PM | 8/24/2020 1:42 PM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2018 10:50:18 AM | 9/11/2019 7:44:10 AM | 9/11/2019 7:44 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Herndon, Sandra
CFO
Bleckley Memorial Hospital
4789346211 | Roland, John
COO
Bleckley Memorial Hospital
4789346211-590 | 8/20/2019 3:17 PM |
| Details | Last Recertification Date | Update | Recertification | 11/20/2017 10:09:14 AM | 8/22/2018 10:50:18 AM | 8/22/2018 10:50 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 000000195A (GA) | | 4/13/2018 11:27 AM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1578637526 ( ) | | 4/13/2018 11:27 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2016 12:00:00 AM | 11/20/2017 10:09:14 AM | 11/20/2017 10:09 AM |
| Contacts | Primary Contact | Update | Recertification | Cranford, Michele
Pharmacy Director
4789346211 | Cranford, Michele
Pharmacy Director
Bleckley Memorial Hospital
4789346211 | 11/20/2017 10:05 AM |
| Contacts | Authorizing Official | Update | | Herndon, Sandra
CFO
4789346211 | Herndon, Sandra
CFO
Bleckley Memorial Hospital
4789346211 | 11/20/2017 9:33 AM |
| Addresses | Main Address | Insert | | |
145 E Peacock St
Cochran, GA 31014 | 8/26/2016 1:39 PM |
| Contacts | Signed By | Insert | | | Hamrick, Jan
CEO
4789346211 | 8/26/2016 1:39 PM |
| Contacts | Primary Contact | Update | | Cranford, Michele
Chief Pharmacist
4789346211 | Cranford, Michele
Pharmacy Director
4789346211 | 8/26/2016 1:39 PM |
| Contacts | Authorizing Official | Update | | Moore, Courtney
CEO
4789346211 | Herndon, Sandra
CFO
4789346211 | 8/26/2016 1:39 PM |
| Details | Last Recertification Date | Update | | 8/11/2015 12:00:00 AM | 8/26/2016 12:00:00 AM | 8/26/2016 1:39 PM |
| Addresses | Billing Address | Insert | | | Bleckley County Hospital
P.O.Box 536
Cochran, GA 31014 | 8/10/2016 9:40 PM |
| Contacts | Authorizing Official | Insert | | | Moore, Courtney
CEO
4789346211 | 8/11/2015 2:23 PM |
| Details | Last Recertification Date | Update | | 8/27/2014 12:00:00 AM | 8/11/2015 12:00:00 AM | 8/11/2015 2:23 PM |
| Contacts | Primary Contact | Insert | | | Cranford, Michele
Chief Pharmacist
4789346211 | 9/8/2014 7:46 AM |
| Details | Last Recertification Date | Update | | 9/5/2013 12:00:00 AM | 8/27/2014 12:00:00 AM | 8/27/2014 2:06 PM |
| Details | Last Recertification Date | Update | | | 9/5/2013 12:00:00 AM | 9/5/2013 5:37 PM |
| Dates | Participating Approval Date | Update | | | 11/3/2011 12:00:00 AM | 11/3/2011 4:09 PM |
| Details | State | Update | | Pending | Active | 11/3/2011 4:09 PM |
| Details | 340B ID | Update | | NEXTQ91 | CAH111302-00 | 10/11/2011 11:15 AM |
| Details | Entity Name | Update | | Bleckley County Hospital | Bleckley County Hospital DBA Bleckley Memorial Hospital | 10/11/2011 11:15 AM |
| Details | Entity Subname | Update | | DBA Bleckley Memorial Hospital | | 10/11/2011 11:15 AM |
| Details | 340B ID | Update | | ONLINE_REG | NEXTQ91 | 9/13/2011 10:12 PM |
| Dates | Start Date | Update | | | 1/1/2012 12:00:00 AM | 9/13/2011 10:12 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 9/13/2011 3:54 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 000000195A | 9/13/2011 3:54 PM |
| Medicaid Billing | Medicaid: State | Insert | | | GA | 9/13/2011 3:54 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1578637526 | 9/13/2011 3:54 PM |
| Details | Last Recertification Date | Insert | | | | 9/13/2011 3:54 PM |
| Details | Grant Number | Insert | | | | 9/13/2011 3:54 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 9/13/2011 3:54 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 9/13/2011 3:54 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 9/13/2011 3:54 PM |
| Details | Medicare Provider Number | Insert | | | 111302 | 9/13/2011 3:54 PM |
| Details | Entity Name | Insert | | | Bleckley County Hospital | 9/13/2011 3:54 PM |
| Details | Program Code | Insert | | | CAH | 9/13/2011 3:54 PM |
| Details | Entity Subname | Insert | | | DBA Bleckley Memorial Hospital | 9/13/2011 3:54 PM |
| Dates | Participating Approval Date | Insert | | | | 9/13/2011 3:54 PM |
| Details | State | Insert | | | Pending | 9/13/2011 3:54 PM |
| Dates | Registration Date | Insert | | | 9/13/2011 12:00:00 AM | 9/13/2011 3:54 PM |
| Dates | Signed By Date | Insert | | | 9/13/2011 12:00:00 AM | 9/13/2011 3:54 PM |
| Dates | Start Date | Insert | | | | 9/13/2011 3:54 PM |
| Terminations | Termination Comments | Insert | | | | 9/13/2011 3:54 PM |
| Terminations | Termination Date | Insert | | | | 9/13/2011 3:54 PM |
| Terminations | Termination Effective Date | Insert | | | | 9/13/2011 3:54 PM |
| Terminations | Termination Reason | Insert | | | | 9/13/2011 3:54 PM |