340B Drug Pricing Program Database


DSH490063 INOVA FAIRFAX HOSPITAL (Active) - information as of 6/12/2025 6:02:26 AM

Main Details
INOVA FAIRFAX HOSPITAL
Disproportionate Share Hospital
No
DSH490063
490063


Additional Details
Active
9/29/2011
10/1/2011
9/29/2011
8/30/2024

Contacts

Inova Fairfax
anuj steve narang, President
(480) 737-1397

Inova Fairfax Medical Campus
Christiana Showunmi, 340B Program Manager
(240) 483-3843

Addresses

3300 Gallows Road
Falls Church, VA 22042

Same as Street Address


  • Comments
  • Medicaid Billing
  • Shipping Addresses
  • Contract Pharmacies
  • Parent/Child
  • History
Comments
CommentLast Updated On 
No records to display.
Medicaid Billing

Yes
StateMedicaid NumberNPI Number
VA49006341184346470,1447686928,1992262612,1972634848,1841632593,1831220714,1093526295
MD49006341831220714
DC49006341831220714
WV49006341831220714
Shipping Addresses

Safecor Health, LLC
317 New Boston Street, Suite 100
Woburn, MA 01801

INOVA FAIRFAX HOSPITAL
3300 Gallows Road
Suite: GP003
IHVI Pharmacy
Falls Church, VA 22042

Inova Pharmacy Plus- ILH
44045 Riverside Parkway
Suite: N1112
Leesburg, VA 20176

Inova Pharmacy Plus - FairOaks
3600 Joseph Siewick Drive
Fairfax, VA 22033

Inova Retail and Specialty Pharmacy
3901 Stonecroft Blvd STE
A1400
Chantilly, VA 20151

Inova Retail Pharmacy-ICPH
8081 Innovation Park Dr FL 2
Fairfax, VA 22031
Contract Pharmacies
Contract DetailPharmacy NameAddressAddress Cont.CityStateZip CodeApproval DateBegin DateCarve-In Effective DateTermination DateLast Updated On
Contract DetailACCREDO HEALTH GROUP INC2040 W RIO SALADO PKWY STE 101B
TEMPEAZ85281-201010/06/202011/09/2020  11/09/2020
Contract DetailACCREDO HEALTH GROUP INC1620 CENTURY CENTER PKWY # 109
MEMPHISTN38134-884910/06/202011/09/2020  11/09/2020
Contract DetailACCREDO HEALTH GROUP INC3000 ERICSSON DRIVE, SUITE 100
WARRENDALEPA15086-750210/06/202011/09/2020  11/09/2020
Contract DetailACCREDO HEALTH GROUP, INC.2 BOULDEN CIR STE 1
NEW CASTLEDE19720-349210/06/202011/09/2020  11/09/2020
Contract DetailACCREDO HEALTH GROUP, INC.6272 LEE VISTA BLVD STE 100
ORLANDOFL3282210/06/202011/09/2020  11/09/2020
Contract DetailACCREDO HEALTH GROUP, INC.2825 W PERIMETER RD STE 112
INDIANAPOLISIN4624110/06/202011/09/2020  11/09/2020
Contract DetailACCREDO HEALTH GROUP, INC.4750 E 450 S SUITE A
WHITESTOWNIN4607501/18/202204/01/2022  04/01/2022
Contract DetailCAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361404/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005604/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005604/15/202007/01/2020  07/01/2020
Contract DetailCAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621904/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621904/15/202007/01/2020  07/01/2020
Contract DetailCAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175704/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808304/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700404/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700404/15/202007/01/2020  07/01/2020
Contract DetailCAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761704/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761704/15/202007/01/2020  07/01/2020
Contract DetailCAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107 		BARTLETTTN3813304/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237404/18/201707/01/2017 03/20/201904/10/2019
Contract DetailCAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A 		REDLANDSCA9237404/15/202007/01/2020  07/01/2020
Contract DetailCOMMCARE PHARMACY-FTL, LLC855 SW 78TH AVE STE C100
PLANTATIONFL33324-322304/14/201607/01/2016 09/13/201804/10/2019
Contract DetailCORAM HEALTHCARE CORPORATION OF GREATERDBA CORAM CVS/SPECIALTY INFUSION SERVICE 7150 COLUMBIA GATEWAY DRIVE
SUITE E 		COLUMBIAMD2104610/16/201701/01/2018 03/20/201904/10/2019
Contract DetailCORAM HEALTHCARE CORPORATION OF GREATERDBA CORAM CVS/SPECIALTY INFUSION SERVICE 4115 PLEASANT VALLEY DRIVE
SUITE 200 		CHANTILLYVA2015110/16/201701/01/2018 03/20/201904/10/2019
Contract DetailCORAM HEALTHCARE CORPORATION OF GREATERDBA CORAM CVS/SPECIALTY INFUSION SERVICE 4115 PLEASANT VALLEY DRIVE
SUITE 200 		CHANTILLYVA2015104/15/202007/01/2020  07/01/2020
Contract DetailCVS CAREMARKDBA CVS/CAREMARK OR CF# 11506 1 GREAT VALLEY BOULEVARD
WILKES BARREPA1870604/15/202007/01/2020  07/01/2020
Contract DetailCVS CAREMARK ADVANCED TECHNOLOGY PHARMACDBA CVS/CAREMARK 48067 1780 WALL ST
MT PROSPECTIL6005604/15/202007/01/2020  07/01/2020
Contract DetailCYSTIC FIBROSIS SERVICES, LLCDBA WALGREENS SPECIALTY PHARMACY #16280 10530 JOHN W ELLIOTT DR STE 200
FRISCOTX7503304/16/202007/01/2020  07/01/2020
Contract DetailDIPLOMAT SPECIALTY PHARMACY4100 S SAGINAW ST STE D
FLINTMI48507-268304/16/202104/21/2021 07/01/202210/14/2022
Contract DetailESI MAIL PHARMACY SERVICEDBA EXPRESS SCRIPTS 7909 S HARDY DR STE 106
TEMPEAZ85284-111210/06/202011/09/2020  11/09/2020
Contract DetailEXPRESS SCRIPTSESI MAIL PHARMACY SERVICE INC 4600 N HANLEY RD
SAINT LOUISMO6313410/06/202011/09/2020  11/09/2020
Contract DetailEXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 4750 E. 450 S.
WHITESTOWNIN4607510/06/202011/09/2020  11/09/2020
Contract DetailEXPRESS SCRIPTS PHARMACY, INC.DBA EXPRESS SCRIPTS 2040 ROUTE 130 NORTH
BURLINGTONNJ0801610/06/202011/09/2020  11/09/2020
Contract DetailINOVA PHARMACY PLUS AT INOVA FAIR OAKS3600 JOSEPH SIEWICK DR
FAIRFAXVA22033-170901/14/202101/26/2021 11/30/202311/30/2023
Contract DetailINOVA RETAIL AND SPECIALTY PHARMACY3901 STONECROFT BLVD STE A1400
CHANTILLYVA2015104/10/201907/01/2019 03/01/202403/01/2024
Contract DetailOPTUM INFUSION SERVICES 103, LLC9204 BERGER RD. STE. A
COLUMBIAMD21046-172904/16/202104/21/2021  04/21/2021
Contract DetailOPTUM INFUSION SERVICES 305, LLC15529 COLLEGE BLVD.
LENEXAKS66219-135104/16/202104/21/2021  04/21/2021
Contract DetailOPTUM PHARMACY 700, LLC5700 DOT COM CT, STE 1000
OVIEDOFL3276504/16/202104/21/2021  04/21/2021
Contract DetailOPTUM PHARMACY 701, LLC4015 SHOPTON RD STE 600
CHARLOTTENC28217-302504/16/202104/21/2021  04/21/2021
Contract DetailOPTUM PHARMACY 701, LLC4100 S SAGINAW ST STE D
FLINTMI4850704/22/202204/28/2022  04/28/2022
Contract DetailOPTUM PHARMACY 702, LLC1050 PATROL RD
JEFFERSONVILLEIN4713004/16/202104/21/2021  04/21/2021
Contract DetailOPTUM PHARMACY 704, INC.5627 UNIVERSITY HTS STE 108
SAN ANTONIOTX7824904/16/202104/21/2021  04/21/2021
Contract DetailOPTUM PHARMACY 705, LLC1100 LEE BRANCH LN
BIRMINGHAMAL35242-729804/16/202104/21/2021  04/21/2021
Contract DetailOPTUM PHARMACY 705, LLC1893 GENERAL GEORGE PATTON DR STE 106
FRANKLINTN37067-265504/16/202104/21/2021  04/21/2021
Contract DetailOPTUM PHARMACY 706, INC.30-30 47TH AVENUE SUITE 410
LONG ISLAND CITYNY1110104/16/202104/21/2021  04/21/2021
Contract DetailOPTUM PHARMACY 801, INC.24416 N 19TH AVE STE. 100
PHOENIXAZ8508504/16/202104/21/2021  04/21/2021
Contract DetailPRIME THERAPEUTICS SPECIALTY PHARMACY LLALLIANCERX WALGREENS PRIME #16568 2354 COMMERCE PARK DRIVE
SUITE 100 		ORLANDOFL32819-999204/16/202007/01/2020 10/01/202210/14/2022
Contract DetailPROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514604/18/201707/01/2017 03/20/201904/10/2019
Contract DetailPROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514604/15/202007/01/2020  07/01/2020
Contract DetailPROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY#2733 1601 17TH STREET NW
WASHINGTONDC2000910/12/201701/01/2018 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01383 7205 LITTLE RIVER TURNPIKE
ANNANDALEVA2200304/18/201707/01/2017 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01397 1452 CHAIN BRIDGE ROAD
MCLEANVA2210104/18/201707/01/2017 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01406 9200 CENTREVILLE RD.
MANASSASVA2011004/18/201707/01/2017 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01411 8124 ARLINGTON BLVD
YORKTOWN CTR 		FALLS CHURCHVA2204204/18/201707/01/2017 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01387 8330 OLD KEENE MILL RD
CARDINAL FOREST 		SPRINGFIELDVA2215210/12/201701/01/2018 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01398 6436 SPRINGFIELD PLAZA
SPRINGFIELDVA2215010/12/201701/01/2018 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01405 8928 BURKE LAKE ROAD
SPRINGFIELDVA2215110/12/201701/01/2018 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01416 5652 PICKWICK RD.
CENTREVILLEVA2012010/12/201701/01/2018 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01417 13031 LEE-JACKSON HIGHWAY
FAIRFAXVA2203310/12/201701/01/2018 09/13/201810/18/2018
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01383 7205 LITTLE RIVER TURNPIKE
ANNANDALEVA2200304/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01402 1062 ELDEN STREET
HERNDONVA2017004/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01404 13600 JEFFERSON DAVIS HIGHWAY
WOODBRIDGEVA2219104/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01417 13031 LEE-JACKSON HIGHWAY
FAIRFAXVA2203304/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01411 8124 ARLINGTON BLVD
YORKTOWN CTR 		FALLS CHURCHVA2204204/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.CVS PHARMACY # 16394 10301 NEW GUINEA RD
FAIRFAXVA2203204/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01389 2912 CHAIN BRIDGE ROAD
OAKTONVA2212404/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01397 1452 CHAIN BRIDGE ROAD
MCLEANVA2210104/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02004 3117 LOCKHEED BLVD
ALEXANDRIAVA2230604/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01416 5652 PICKWICK RD.
CENTREVILLEVA2012004/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02317 6637 ARLINGTON BLVD.
FALLS CHURCHVA2204204/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02343 5101 DUKE STREET
ALEXANDRIAVA2230404/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01399 3053 NUTLEY STREET
FAIRFAXVA2203104/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01832 4338 DALE BLVD.
DALE CITYVA2219304/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01390 9582 OLD KEENE MILL ROAD
BURKEVA2201504/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01405 8928 BURKE LAKE ROAD
SPRINGFIELDVA2215104/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01378 5711 BURKE CENTER PARKWAY
BURKEVA2201504/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01413 7859 HERITAGE DRIVE
ANNANDALEVA2200304/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01400 1150 WEST BROAD STREET
FALLS CHURCHVA2204604/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02100 9009 SILVERBROOK ROAD
FAIRFAX STATIONVA2203904/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01387 8330 OLD KEENE MILL RD
CARDINAL FOREST 		SPRINGFIELDVA2215204/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02453 11003 LEE HWY
FAIRFAXVA2203004/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01371 10390 WILLARD WAY
FAIRFAXVA2203004/15/202007/01/2020 04/11/202307/17/2023
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01406 9200 CENTREVILLE RD.
MANASSASVA2011004/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA CVS/PHARMACY # 10170 8117 LEESBURG PIKE
VIENNAVA2218204/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01993 24795 PINEBROOK RD
SOUTH RIDINGVA2015204/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01396 11160 SOUTH LAKES DRIVE
RESTONVA2019104/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01398 6436 SPRINGFIELD PLAZA
SPRINGFIELDVA2215004/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 01403 337 EAST MAPLE STREET
VIENNAVA2218004/15/202007/01/2020  07/01/2020
Contract DetailVIRGINIA CVS PHARMACY, L.L.C.DBA: CVS/PHARMACY # 02003 3921 PROSPERITY AVE
FAIRFAXVA2203104/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #12359 1517 MOUNT VERNON AVE
ALEXANDRIAVA2230104/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS # 09949 42025 VILLAGE CENTER
ALDIEVA20105-302704/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #10503 43250 SOUTHERN WALK PLAZA
BROADLANDSVA2014804/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #10233 7629 RICHMOND HWY.
ALEXANDRIAVA22306-280204/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #10616 6717 RICHMOND HWY.
ALEXANDRIAVA22306-670404/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #11299 12601 SMOKETOWN RD.
WOODBRIDGEVA2219204/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #09837 20321 SUSAN LESLIE DR.
ASHBURNVA2014704/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #11297 3050A NUTLEY ST.
FAIRFAXVA2203104/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #10331 13926 LEE HWY.
CENTREVILLEVA2012004/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #10822 4985 WELLINGTON RD.
GAINESVILLEVA2015504/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #11912 9271 SUDLEY RD.
MANASSASVA2011004/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS # 09383 276 W LEE HWY
WARRENTONVA2018604/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #11525 9372 RICHMOND HWY.
LORTONVA2207904/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #10165 603 ELDEN ST.
HERNDONVA20170-472204/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #10976 9001 WOODY TER STE C
CLINTONMD2073504/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #10712 10320 MAIN ST.
FAIRFAXVA2203004/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #12167 9150 DEVLIN RD.
BRISTOWVA2013604/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #11234 10671 SUDLEY MANOR DR.
MANASSASVA2010904/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #11675 15250 MONTANUS DR.
CULPEPERVA2270104/15/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #12361 25421 EASTERN MARKETPLACE PLZ.
CHANTILLYVA2015204/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #13012 6400 HOADLY RD.
MANASSASVA2011204/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #13941 3130 LANGSTON BLVD
ARLINGTONVA2220104/16/202007/01/2020 11/06/202411/26/2024
Contract DetailWALGREEN CO.DBA: WALGREENS #13970 4300 BACKLICK RD
ANNANDALEVA2200304/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #15444 6715A ARLINGTON BLVD
FALLS CHURCHVA2204204/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #13682 761 E. MAIN ST.
PURCELLVILLEVA2013204/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #13790 14095 RICHMOND HWY
WOODBRIDGEVA2219104/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #13589 225 MAPLE AVE. EAST
VIENNAVA22180-463004/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #13989 10213 DUMFRIES RD.
MANASSASVA2011004/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.DBA: WALGREENS #12800 8414 OLD KEENE MILL RD.
UNIT A 		SPRINGFIELDVA2215204/16/202007/01/2020  07/01/2020
Contract DetailWALGREEN CO.COMMUNITY, A WALGREENS PHARMACY #21142 1015 RIPLEY STREET
STE B 		SILVER SPRINGMD2091004/16/202007/01/2020  07/01/2020
Contract DetailWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #16287 130 ENTERPRISE DR
PITTSBURGHPA1527504/16/202007/01/2020  07/01/2020
Contract DetailWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15443 10530 JOHN W ELLIOTT DR STE 100
FRISCOTX7503304/16/202007/01/2020  07/01/2020
Contract DetailWALGREENS SPECIALTY PHARMACY, LLCALLIANCERX WALGREENS PRIME #12314 9775 SW GEMINI DR, STE 1
BEAVERTONOR9700804/16/202007/01/2020 10/01/202110/13/2021
Contract DetailWALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15438 41460 HAGGERTY CIR S
CANTONMI4818804/16/202007/01/2020  07/01/2020
Contract DetailWEGMANS FOOD MARKETS, INC.45131 COLUMBIA PLACE ATTN: PHARMACY
STERLINGVA2016610/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.11620 MONUMENT DRIVE ATTN: PHARMACY
FAIRFAXVA2203010/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.2281 CARL D. SILVER PARKWAY ATTN: PHARMACY
FREDERICKSBURGVA2240110/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.8297 STONEWALL SHOPS SQUARE ATTN: PHARMACY
GAINESVILLEVA2015510/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.101 CROSSTAIL BLVD. SE ATTN: PHARMACY
LEESBURGVA2017510/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.7905 HILLTOP VILLAGE CENTER DRIVE
ALEXANDRIAVA2231510/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.100 WEGMANS WAY
CHARLOTTESVILLEVA2290210/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.12501 STONE VILLAGE WAY WEGMANS PHARMACY 129
MIDLOTHIANVA2311310/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.12200 WEGMANS BLVD.
HENRICOVA2323310/16/201701/01/2018 09/13/201810/18/2018
Contract DetailWEGMANS FOOD MARKETS, INC.14801 DINING WAY ATTN: PHARMACY
WOODBRIDGEVA2219110/16/201701/01/2018 09/13/201810/18/2018
Parent/Child
340B IDHierarchyEntity TypeNameSub NameAddressCityState340B Status
DSH490063AChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Infusion Center: ISCI Peds Infusion8081 Innovation Park DriveFairfaxVAActive
DSH490063AAChildDSHINOVA FAIRFAX HOSPITALRiverStone Clinic - Surgical Breast Clinc8081 Innovation Park DriveFairfaxVAActive
DSH490063ABChildDSHINOVA FAIRFAX HOSPITALSkyline Clinic - Malignant & Benign Clinic8081 Innovation Park DriveFairfaxVAActive
DSH490063ACChildDSHINOVA FAIRFAX HOSPITALWhite Oak Clinic - Head & Neck/ Neuro/ Palliative/ Endocrine/Thoracic Clinic/Geriatric Onc/Adv Solid Tumor8081 Innovation Park DriveFairfaxVAActive
DSH490063ADChildDSHINOVA FAIRFAX HOSPITALInfusion Center- IFH EAST - Mark Center Infusion1800 N Beauregard StAlexandriaVAActive
DSH490063AEChildDSHINOVA FAIRFAX HOSPITALGreat Falls Clinic - GI,GU8081 Innovation Park DriveFairfaxVAActive
DSH490063AFChildDSHINOVA FAIRFAX HOSPITALInova Ewing FACT Department- Alexandria - Forensic Assessment and Consultation Teams4700 King StreetAlexandriaVAActive
DSH490063AGChildDSHINOVA FAIRFAX HOSPITALFairfax Hospital -ISCI Clinic -Fairfax West - Hematology Oncology3580 Joseph Siewick DriveFairfaxVAActive
DSH490063AHChildDSHINOVA FAIRFAX HOSPITALInterventional Pulmonology- ISCI - Interventional Pulmonology8081 Innovation Park DrFairfaxVATerminated
DSH490063AJChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Infusion Center: Loudoun Infusion44045 Riverside ParkwayLeesburgVAActive
DSH490063AKChildDSHINOVA FAIRFAX HOSPITALFairfax Hospital- ISCI Clinic- Fairfax East - Mark Center Clinic1800 N Beauregard StAlexandriaVAActive
DSH490063ALChildDSHINOVA FAIRFAX HOSPITALInova Fairfax Hospital - ISCI Clinic - IFH Loudoun - Oncology44055 Riverside ParkwayLeesburgVAActive
DSH490063AMChildDSHINOVA FAIRFAX HOSPITALInova Fairfax Hospital: Neurology Clinic - Neurology Clinic at Alexandria1500 N Beauregard StAlexandriaVAActive
DSH490063ANChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Clinic - IFH ISCI Clinic: Phase 1 Research8081 Innovation Park DriveFairfaxVAActive
DSH490063APChildDSHINOVA FAIRFAX HOSPITALInova Fairfax Hospital: Neurology Clinic - Neurology Clinic at ICPH8081 Innovation Park DriveFairfaxVAActive
DSH490063AQChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Saville Center - Saville Prevention and Screening Center Clinic8081 Innovation Park DriveFairfaxVAActive
DSH490063ARChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Saville Center - Saville Prevention and Screening Center Procedural Area8081 Innovation Park DriveFairfaxVAActive
DSH490063ASChildDSHINOVA FAIRFAX HOSPITALICPH Pre Abdominal Transplant Clinic - Transplant8081 Innovation Park DriveFairfaxVAActive
DSH490063ATChildDSHINOVA FAIRFAX HOSPITALICPH Post Abdominal Transplant Clinic - Transplant8081 Innovation Park DriveFairfaxVAActive
DSH490063AUChildDSHINOVA FAIRFAX HOSPITALInova Fairfax Hospital: Neurosurgery Clinic - Neurosurgery Clinic at Dumfries - Neurosurgery3800 Fettler ParkDumfriesVAActive
DSH490063AVChildDSHINOVA FAIRFAX HOSPITALInova Fairfax Hospital: Neurology Clinic - Neurology Clinic at Dumfries - Neurology3800 Fettler ParkDumfriesVAActive
DSH490063AWChildDSHINOVA FAIRFAX HOSPITALInova Fairfax Hospital: Neurosurgery Clinic - Neurosurgery Clinic at Alexandria - Neurosurgery1500 N Beauregard StAlexandriaVAActive
DSH490063AXChildDSHINOVA FAIRFAX HOSPITALInova Fairfax Hospital: Neurosurgery Clinic - Neurosurgery Clinic at ICPH - Neurosurgery8081 Innovation Park DriveFairfaxVAActive
DSH490063AYChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Clinic - Survivorship - Survivorship8081 Innovation Park DriveFairfaxVAActive
DSH490063AZChildDSHINOVA FAIRFAX HOSPITALPain Management - ICPH - Pain Management8081 Innovation Park DriveFairfaxVAActive
DSH490063BChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Infusion Center: Adult Infusion8081 Innovation Park DriveFairfaxVAActive
DSH490063BAChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Infusion Center - Cellular Therapy - Cellular Therapy8081 Innovation Park DriveFairfaxVAActive
DSH490063BBChildDSHINOVA FAIRFAX HOSPITALIFH ISCI Infusion Center - Phase 1 Research - Phase 1 Research8081 Innovation Park DriveFairfaxVAActive
DSH490063CChildDSHINOVA FAIRFAX HOSPITALWoodburn Surgery Center3289 Woodburn RoadAnnandaleVAActive
DSH490063DChildDSHINOVA FAIRFAX HOSPITALImaging Center- Gainesville13575 Heathcote Blvd.GainesvilleVAActive
DSH490063EChildDSHINOVA FAIRFAX HOSPITALVein and Vascular Center13575 Heathcote Blvd.GainesvilleVATerminated
DSH490063FChildDSHINOVA FAIRFAX HOSPITALEmergency Care Center4315 Chain Bridge RoadFairfaxVAActive
DSH490063GChildDSHINOVA FAIRFAX HOSPITALEmergency Care Center11901 Baron Cameron AveRestonVAActive
DSH490063HChildDSHINOVA FAIRFAX HOSPITALWoodburn Post Anethesia Care Unit 3289 Woodburn RoadAnnandaleVAActive
DSH490063JChildDSHINOVA FAIRFAX HOSPITALEmergency Care Center - Reston / Laboratory11901 Baron Cameron AveRestonVATerminated
DSH490063KChildDSHINOVA FAIRFAX HOSPITALInova Fairfax Hospital - Reston / X-Ray11901 Baron Cameron AveRestonVATerminated
DSH490063LChildDSHINOVA FAIRFAX HOSPITALEmergency Care Center - Fairfax / Laboratory4315 Chain Bridge RoadFairfaxVATerminated
DSH490063MChildDSHINOVA FAIRFAX HOSPITALEmergency Care Center - Fairfax / X-Ray4315 Chain Bridge RoadFairfaxVATerminated
DSH490063NChildDSHINOVA FAIRFAX HOSPITALEmergency Care Center - Fairfax / CT Scanner4315 Chain Bridge RoadFairfaxVAActive
DSH490063PChildDSHINOVA FAIRFAX HOSPITALIFH West Infusion Center3580 Joseph Siewick DriveFairfaxVAActive
DSH490063QChildDSHINOVA FAIRFAX HOSPITALRadiation Oncology - ISCI Oncology8081 Innovation Park DriveFairfaxVAActive
DSH490063RChildDSHINOVA FAIRFAX HOSPITALCardiac Diagnostics - ISCI Cardiology8081 Innovation Park DriveFairfaxVAActive
DSH490063SChildDSHINOVA FAIRFAX HOSPITALArlington Blvd Cardiology - Arlington Blvd Cardiology8505 Arlington BlvdFairfaxVATerminated
DSH490063TChildDSHINOVA FAIRFAX HOSPITALChesapeake Clinic - Melanoma Dermatology Oncology Clinic8081 Innovation Park DriveFairfaxVAActive
DSH490063UChildDSHINOVA FAIRFAX HOSPITALAbdominal Transplant Clinic - Pre-Kidney Transplant3300 Gallows RoadFalls ChurchVATerminated
DSH490063VChildDSHINOVA FAIRFAX HOSPITALAbdominal Transplant Clinic - Post Transplant Abdominal3300 Gallows RoadFalls ChurchVATerminated
DSH490063WChildDSHINOVA FAIRFAX HOSPITALInova Ewing FACT Department - Forensic Assessment and Consultation Teams2671 Avenir PlaceViennaVAActive
DSH490063XChildDSHINOVA FAIRFAX HOSPITALPotomac Clinic - Medical Breast Clinic8081 Innovation Park DriveFairfaxVAActive
DSH490063YChildDSHINOVA FAIRFAX HOSPITALPeds Sedation Services - ISCI Peds Sedation Services8081 Innovation Park DriveFairfaxVAActive
DSH490063ZChildDSHINOVA FAIRFAX HOSPITALDiagnostic Imaging - ISCI Diagnostic Imaging8081 Innovation Park DriveFairfaxVAActive
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
AddressesShipping AddressUpdateChange RequestInova Retail and Specialty Pharmacy 8081 Innovation Park Drive Fairfax, VA 22031Inova Retail and Specialty Pharmacy 3901 Stonecroft Blvd STE A1400 Chantilly, VA 201515/15/2025 11:00 AM
AddressesShipping AddressUpdateChange RequestInova Retail Pharmacy-ICPH 3901 Stonecroft Blvd A1400 Chantilly, VA 20151Inova Retail Pharmacy-ICPH 8081 Innovation Park Dr FL 2 Fairfax, VA 220315/15/2025 11:00 AM
AddressesShipping AddressInsertChange Request Inova Retail Pharmacy-ICPH 3901 Stonecroft Blvd A1400 Chantilly, VA 201512/26/2025 10:31 AM
Medicaid BillingNPI: NumberInsertChange Request 10935262952/26/2025 10:31 AM
Medicaid BillingNPI: StateInsertChange Request VA2/26/2025 10:31 AM
DetailsLast Recertification DateUpdateRecertification8/29/2023 8:53:20 PM8/30/2024 8:06:50 AM8/30/2024 8:06 AM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False4/12/2024 11:06 AM
Medicaid BillingMedicaid: NumberInsertChange Request 49006344/12/2024 11:06 AM
Medicaid BillingMedicaid: StateInsertChange Request MD4/12/2024 11:06 AM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False4/12/2024 11:06 AM
Medicaid BillingMedicaid: NumberInsertChange Request 49006344/12/2024 11:06 AM
Medicaid BillingMedicaid: StateInsertChange Request DC4/12/2024 11:06 AM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False4/12/2024 11:06 AM
Medicaid BillingMedicaid: NumberInsertChange Request 49006344/12/2024 11:06 AM
Medicaid BillingMedicaid: StateInsertChange Request WV4/12/2024 11:06 AM
Medicaid BillingNPI: NumberInsertChange Request 18312207144/12/2024 11:06 AM
Medicaid BillingNPI: StateInsertChange Request MD4/12/2024 11:06 AM
Medicaid BillingNPI: NumberInsertChange Request 18312207144/12/2024 11:06 AM
Medicaid BillingNPI: StateInsertChange Request DC4/12/2024 11:06 AM
Medicaid BillingNPI: NumberInsertChange Request 18312207144/12/2024 11:06 AM
Medicaid BillingNPI: StateInsertChange Request WV4/12/2024 11:06 AM
AddressesShipping AddressInsertChange Request Inova Retail and Specialty Pharmacy 8081 Innovation Park Drive Fairfax, VA 220312/15/2024 9:53 AM
Medicaid BillingNPI: NumberInsertChange Request 19922626122/15/2024 9:53 AM
Medicaid BillingNPI: StateInsertChange Request VA2/15/2024 9:53 AM
AddressesShipping AddressInsertChange Request Inova Pharmacy Plus - FairOaks 3600 Joseph Siewick Drive Fairfax, VA 2203311/27/2023 12:13 PM
Medicaid BillingNPI: NumberInsertChange Request 184163259311/27/2023 12:13 PM
Medicaid BillingNPI: StateInsertChange Request VA11/27/2023 12:13 PM
DetailsLast Recertification DateUpdateRecertification9/1/2022 6:32:12 PM8/29/2023 8:53:20 PM8/29/2023 8:53 PM
AddressesShipping AddressUpdateChange RequestInova Pharmacy Plus- ILH 44045 Riverside Parkway Suite: 01D033 Leesburg, VA 20176Inova Pharmacy Plus- ILH 44045 Riverside Parkway Suite: N1112 Leesburg, VA 201762/28/2023 7:45 AM
AddressesShipping AddressInsertChange Request Inova Pharmacy Plus- ILH 44045 Riverside Parkway Suite: 01D033 Leesburg, VA 2017612/14/2022 8:58 AM
Medicaid BillingNPI: NumberInsertChange Request 118434647012/14/2022 8:58 AM
Medicaid BillingNPI: StateInsertChange Request VA12/14/2022 8:58 AM
DetailsLast Recertification DateUpdateRecertification9/15/2021 7:25:53 AM9/1/2022 6:32:12 PM9/1/2022 6:32 PM
AddressesShipping AddressDeleteChange RequestInova Loudoun Hospital Pharmacy 44045 Riverside Pkwy Leesburg, VA 20176 4/25/2022 12:18 PM
AddressesShipping AddressInsertChange Request Inova Loudoun Hospital Pharmacy 44045 Riverside Pkwy Leesburg, VA 2017610/13/2021 9:53 AM
DetailsLast Recertification DateUpdateRecertification8/28/2020 10:01:12 AM9/15/2021 7:25:53 AM9/15/2021 7:25 AM
ContactsPrimary ContactUpdateProfile Change RequestShowunmi, Christiana 340B Program Manager Inova Fairfax Medical Campus 7037761114Showunmi, Christiana 340B Program Manager Inova Fairfax Medical Campus 24048338439/7/2021 11:13 AM
AddressesShipping AddressDeleteChange RequestINOVA FAIRFAX HOSPITAL 3300 Gallows Road IHVI Pharmacy Falls Church, VA 22042 12/28/2020 9:17 AM
AddressesShipping AddressInsertChange Request INOVA FAIRFAX HOSPITAL 3300 Gallows Road Suite: GP003 IHVI Pharmacy Falls Church, VA 2204212/28/2020 9:17 AM
Medicaid BillingNPI: StateUpdateRecertification VA8/28/2020 10:01 AM
Medicaid BillingNPI: StateUpdateRecertification VA8/28/2020 10:01 AM
Medicaid BillingNPI: StateUpdateRecertification VA8/28/2020 10:01 AM
DetailsLast Recertification DateUpdateRecertification9/11/2019 2:30:37 PM8/28/2020 10:01:12 AM8/28/2020 10:01 AM
ContactsPrimary ContactUpdateProfile Change RequestShowunmi, Christiana 340B Compliance Pharmacist Inova Fairfax Medical Campus 7037761114Showunmi, Christiana 340B Program Manager Inova Fairfax Medical Campus 70377611148/12/2020 12:05 PM
AddressesShipping AddressDeleteChange RequestINOVA FAIRFAX HOSPITAL 3300 Gallows Road Falls Church, VA 22042 6/1/2020 6:57 AM
AddressesShipping AddressInsertChange Request INOVA FAIRFAX HOSPITAL 3300 Gallows Road IHVI Pharmacy Falls Church, VA 220426/1/2020 6:57 AM
Medicaid BillingNPI: NumberDeleteChange Request1881018489 ( ) 6/1/2020 6:57 AM
Medicaid BillingNPI: NumberInsertChange Request 18810184893/11/2020 8:43 AM
Medicaid BillingNPI: NumberInsertChange Request 14476869283/11/2020 8:43 AM
ContactsPrimary ContactUpdateChange RequestPipan, Jonathan Marcus 340B Program Coordinator Inova Fairfax Medical Campus 7037762944Showunmi, Christiana 340B Compliance Pharmacist Inova Fairfax Medical Campus 70377611141/9/2020 8:04 AM
ContactsPrimary ContactUpdateRecertificationFord, Raneesha Sr. Director, Pharmacy Services Inova Fairfax Medical Campus 7037762940Pipan, Jonathan Marcus 340B Program Coordinator Inova Fairfax Medical Campus 70377629449/11/2019 2:30 PM
DetailsLast Recertification DateUpdateRecertification8/22/2018 4:41:26 PM9/11/2019 2:30:37 PM9/11/2019 2:30 PM
ContactsAuthorizing OfficialUpdateAO Change RequestCarroll, Susan CEO Inova Fairfax Medical Campus/Hospital 7037763050narang, anuj steve President Inova Fairfax 48073713979/3/2019 9:43 AM
AddressesShipping AddressInsertChange Request INOVA FAIRFAX HOSPITAL 3300 Gallows Road Falls Church, VA 220426/18/2019 1:54 PM
AddressesShipping AddressInsertChange Request Safecor Health, LLC 317 New Boston Street, Suite 100 Woburn, MA 018016/18/2019 1:54 PM
Medicaid BillingNPI: NumberDeleteChange Request1588717755 ( ) 4/10/2019 1:30 PM
ContactsAuthorizing OfficialUpdateChange RequestChristiansen, Patrick CEO Inova Fairfax Medical Campus 7037763050Carroll, Susan CEO Inova Fairfax Medical Campus/Hospital 703776305011/5/2018 2:45 PM
DetailsLast Recertification DateUpdateRecertification11/8/2017 2:12:52 PM8/22/2018 4:41:26 PM8/22/2018 4:41 PM
ContactsPrimary ContactUpdateProfile Change RequestFord, Raneesha Pharmacy Director of Operations Inova Fairfax Medical Campus 7037766650Ford, Raneesha Sr. Director, Pharmacy Services Inova Fairfax Medical Campus 70377629407/16/2018 2:25 PM
ContactsPrimary ContactUpdateChange RequestDupart, Patrice Senior Director of Pharmacy Services Inova Fairfax Medical Campus 7037762940Ford, Raneesha Pharmacy Director of Operations Inova Fairfax Medical Campus 70377666502/16/2018 9:16 AM
DetailsLast Recertification DateUpdateRecertification8/25/2016 12:00:00 AM11/8/2017 2:12:52 PM11/8/2017 2:12 PM
ContactsPrimary ContactUpdateRecertificationDupart, Patrice Senior Director of Pharmacy Services 7037762940Dupart, Patrice Senior Director of Pharmacy Services Inova Fairfax Medical Campus 703776294010/26/2017 10:27 AM
ContactsAuthorizing OfficialUpdate Christiansen, Patrick CEO 7037763050Christiansen, Patrick CEO Inova Fairfax Medical Campus 70377630509/20/2017 3:38 PM
ContactsAuthorizing OfficialUpdate PASTERNAK, REUVEN CEO 7037763230Christiansen, Patrick CEO 70377630504/18/2017 11:23 AM
ContactsPrimary ContactUpdate Massiah-White, Melanie Interim Director of Pharmacy 7037762940Dupart, Patrice Senior Director of Pharmacy Services 703776294011/14/2016 4:03 PM
AddressesMain AddressInsert   3300 Gallows Road Falls Church, VA 2204211/14/2016 4:03 PM
Medicaid BillingNPI: NumberInsert  158871775511/2/2016 9:50 AM
Medicaid BillingNPI: NumberInsert  197263484811/2/2016 9:50 AM
DetailsLast Recertification DateUpdate 8/25/2015 12:00:00 AM8/25/2016 12:00:00 AM8/25/2016 2:41 PM
Medicaid BillingNPI: NumberInsert  183122071410/7/2015 1:21 PM
DetailsLast Recertification DateUpdate 9/5/2014 12:00:00 AM8/25/2015 12:00:00 AM8/25/2015 4:45 PM
ContactsPrimary ContactUpdate Ershadi, Mahro Director of Pharmacy 7037762940Massiah-White, Melanie Interim Director of Pharmacy 70377629409/5/2014 6:25 PM
DetailsLast Recertification DateUpdate 9/12/2013 12:00:00 AM9/5/2014 12:00:00 AM9/5/2014 6:25 PM
DetailsLast Recertification DateUpdate  9/12/2013 12:00:00 AM9/12/2013 2:24 PM
ContactsPrimary ContactUpdate WANDRES, DANIEL CHIEF PHARMACY OFFICER 7032052140Ershadi, Mahro Director of Pharmacy 70377629404/6/2012 3:02 PM
ContactsAuthorizing OfficialInsert  PASTERNAK, REUVEN CEO 70377632304/6/2012 3:02 PM
ContactsPrimary ContactInsert  WANDRES, DANIEL CHIEF PHARMACY OFFICER 70320521409/29/2011 12:33 PM
DatesParticipating Approval DateUpdate  9/29/2011 12:00:00 AM9/29/2011 12:33 PM
DetailsStateUpdate PendingActive9/29/2011 12:33 PM
Medicaid BillingMedicaid: Is PrimaryInsert  False9/29/2011 12:00 PM
Medicaid BillingMedicaid: NumberInsert  49006349/29/2011 12:00 PM
Medicaid BillingMedicaid: StateInsert  VA9/29/2011 12:00 PM
DetailsLast Recertification DateInsert   9/29/2011 12:00 PM
DetailsGrant NumberInsert   9/29/2011 12:00 PM
Details340B IDInsert  DSH4900639/29/2011 12:00 PM
DetailsIs Authorizing Official EHB DataInsert   9/29/2011 12:00 PM
DatesLast Date That 340B Drugs PurchasedInsert   9/29/2011 12:00 PM
DetailsMedicare Provider NumberInsert  4900639/29/2011 12:00 PM
DetailsEntity NameInsert  INOVA FAIRFAX HOSPITAL9/29/2011 12:00 PM
DetailsProgram CodeInsert  DSH9/29/2011 12:00 PM
DetailsEntity SubnameInsert   9/29/2011 12:00 PM
DatesParticipating Approval DateInsert   9/29/2011 12:00 PM
DetailsStateInsert  Pending9/29/2011 12:00 PM
DatesRegistration DateInsert  9/29/2011 12:00:00 AM9/29/2011 12:00 PM
DatesSigned By DateInsert   9/29/2011 12:00 PM
DatesStart DateInsert  10/1/2011 12:00:00 AM9/29/2011 12:00 PM
TerminationsTermination CommentsInsert   9/29/2011 12:00 PM
TerminationsTermination DateInsert   9/29/2011 12:00 PM
TerminationsTermination Effective DateInsert   9/29/2011 12:00 PM
TerminationsTermination ReasonInsert   9/29/2011 12:00 PM