Covered Entity Details

DSH390256N MILTON S. HERSHEY MEDICAL CENTER (Active) - information as of 4/28/2025 12:40:50 AM

Main Details

Name

MILTON S. HERSHEY MEDICAL CENTER

Subdivision Name

PSHMG Middletown Surgery Specialties

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH390256N

Medicare Provider Number

390256

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

11/30/2011

Participating Start Date

12/8/2011

Participating Approval Date

12/8/2011

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Penn State Health
Tracy L Moyer, Senior Vice President of Financial Operations
(717) 531-8477

Primary Contact

Penn State Health
Samuel Wetherill, VP Pharmacy
(410) 920-4494

Addresses

Street Address

3100 Schoolhouse Rd
Suite 100
Middletown, PA 17057

Billing Address

Penn State Milton S. Hershey Medical Center
500 University Dr
Hershey, PA 17033

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

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

State	Medicaid Number	NPI Number
PA	1007653100005	1568435477

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH390256AA	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Obstetrics & Gynecology - REPRODUCTIVE ENDOCRINOLOGY	35 Hope Drive	Hershey	PA	Active
DSH390256AB	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Pediatric Bone & Joint (Spina Bifida)	30 Hope Drive	HERSHEY	PA	Terminated
DSH390256AC	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Therapy Services (Speech Therapy)	30 Hope Drive	Hershey	PA	Active
DSH390256AD	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Therapy Services (Occupational Therapy)	30 Hope Drive	Hershey	PA	Active
DSH390256AE	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Therapy Services (Physical Therapy)	30 Hope Drive	Hershey	PA	Active
DSH390256AF	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Briarcrest (Diabetes & Weight)	905 W. Governor Road	Hershey	PA	Active
DSH390256AG	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Briarcrest (Adolescent Medicine)	905 W. Governor Road	Hershey	PA	Active
DSH390256AH	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Briarcrest (Pediatric Specialties)	905 W. Governor Road	Hershey	PA	Active
DSH390256AJ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Mount Joy	201 Lefever Rd.	Mount Joy	PA	Active
DSH390256AK	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Psychiatry	22 North East Dr.	HERSHEY	PA	Active
DSH390256AL	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	PSHMG Camp Hill HVI / Heart and Vascular	3025 Market St.	Camp Hill	PA	Terminated
DSH390256AM	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	PSHMG Camp Hill / Echocardiogram	3025 Market St.	camp Hill	PA	Terminated
DSH390256AN	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Road II / Echocardiogram	121 Nyes Road	Harrisburg	PA	Terminated
DSH390256AP	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Neurophysiology	30 Hope Drive	Hershey	PA	Active
DSH390256AQ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Plastic Surgery	30 Hope Drive	Hershey	PA	Active
DSH390256AR	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Palmyra HVI / Heart and Vascular	941 Park Dr.	Palmyra	PA	Active
DSH390256AS	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Breast Imaging / Diagnostic Imaging	30 Hope Dr.	Hershey	PA	Terminated
DSH390256AT	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Penn State Hershey Medical Group Nyes Rd. / Diagnostic Imaging	121 Nyes Rd.	Harrisburg	PA	Terminated
DSH390256AU	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	"PSHMG Mechanicsburg Family Medicine"	140 Old Willow Mill Road	Mechanicsburg	PA	Active
DSH390256AV	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Cocoaplex-Medicine - Multi Specialty	1150 Cocoa Avenue	Hershey	PA	Active
DSH390256AW	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Pediatric Specialties - Pediatric specialties	200 Campus Drive	Hershey	PA	Active
DSH390256AX	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Pain Medicine - Pain management UPC	200 Campus Drive	Hershey	PA	Active
DSH390256AY	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Renal Dialysis (Hemodialysis) - Hemodialysis	200 Campus Drive	Hershey	PA	Active
DSH390256AZ	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Surgery Specialties (IBD Center) - Irritable bowel disease	200 Campus Drive	Hershey	PA	Terminated
DSH390256B	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Campe Hill Entrance B.Family Med - General	3025 Market St	Camp Hill	PA	Active
DSH390256BA	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Heart & Vascular Services - Cardiology services UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BB	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Medicine Specialties - Medicine specialties	200 Campus Drive	Hershey	PA	Terminated
DSH390256BC	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Ophthalmology - Ophthalmology	200 Campus Drive	Hershey	PA	Active
DSH390256BD	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Practice Management Clinic – Anesthesia Clinic	200 Campus Drive	Hershey	PA	Active
DSH390256BE	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Otolaryngology - Head/Neck surgical services	200 Campus Drive	Hershey	PA	Terminated
DSH390256BF	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Cancer Institute (Practice Site) - Office visits	400 University Drive	Hershey	PA	Active
DSH390256BG	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Cancer Institute (Hem/Onc & Infusion) - Hematology/Oncology and Infusion	400 University Drive	Hershey	PA	Active
DSH390256BH	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Pediatric Hem/Onc & Infusion - Hematology/Oncology and Infusion	600 University Drive	Hershey	PA	Active
DSH390256BJ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Dermatology UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BK	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	West Campus Allergy Asthma & Immunology	10 Conference Drive	Hershey	PA	Active
DSH390256BL	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Endoscopy UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BN	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Surgery Specialties UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BP	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Audiology UPC	200 Campus Drive	Hershey	PA	Active
DSH390256BQ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Renal Dialysis (Peritineal) - Peritineal	200 Campus Drive	Hershey	PA	Active
DSH390256BR	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Medicine Suite - Medicine Specialties	200 Campus Drive	Hershey	PA	Active
DSH390256BS	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Medicine Specialties (Diabetes) - Diabetes Education	200 Campus Drive	Hershey	PA	Active
DSH390256BT	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PENN STATE HERSHEY-LIME SPRINGS - Therapy Services	2221 NOLL DRIVE	LANCASTER	PA	Active
DSH390256BU	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG - Pediatric Specialties Lancaster	1430 Harrisburg Pike	LANCASTER	PA	Active
DSH390256BV	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PENN STATE HERSHEY-LIME SPRINGS - Infusion	2221 NOLL DRIVE	LANCASTER	PA	Active
DSH390256BW	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	"PSHMG Lime Springs Specialties"	2221 NOLL DRIVE	LANCASTER	PA	Active
DSH390256BX	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PENN STATE HERSHEY-LIME SPRINGS - Audiology	2221 NOLL DRIVE	LANCASTER	PA	Active
DSH390256BY	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSMG HOPE DR 35 - Internal Medicine	35 HOPE DRIVE	HERSHEY	PA	Active
DSH390256BZ	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSMG NYES ROAD - Audiology	121 NYES ROAD	HARRISBURG	PA	ToBeTerminated
DSH390256C	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Camp Hill Specialties	3025 Market St	Camp Hill	PA	Active
DSH390256CA	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSMG HOPE DR 35 - Womens Health	35 HOPE DRIVE	HERSHEY	PA	Active
DSH390256CB	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Campus Drive Suite 1300- Medicine-Pulmonology General - Pulmonology	200 Campus Dr.	Hershey	PA	Approved
DSH390256D	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Harrisburg	2626 North Third Street	Harrisburg	PA	Active
DSH390256E	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Road II	121 Nyes Road Suite F	Harrisburg	PA	Active
DSH390256F	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Rd Pediatric Cardiology	121 Nyes Road Suite D	Harrisburg	PA	Active
DSH390256G	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Road I	121 Nyes Road Suite A	Harrisburg	PA	Active
DSH390256H	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Fishburn Road	845 Fishburn Rd	Hershey	PA	Active
DSH390256J	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Road Specialties	121 Nyes Rd Suite C	Harrisburg	PA	Active
DSH390256K	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Middletown	3100 Schoolhouse Rd	Middletown	PA	Active
DSH390256L	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Nyes Rd Heart & Vascular	121 Nyes Road Suite E	Harrisburg	PA	Active
DSH390256M	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Elizabethtown	1 Continental Dr	Elizabethtown	PA	Active
DSH390256N	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Middletown Surgery Specialties	3100 Schoolhouse Rd	Middletown	PA	Active
DSH390256P	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Palmyra	941 Park Dr	Palmyra	PA	Active
DSH390256Q	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	PSHCH - Lancaster Outpatient	2170 Noll Dr	Lancaster	PA	Terminated
DSH390256R	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	PSHMG Physical Medicine Rehab	1135 Old West Chocolate Avenue	Hummelstown	PA	Active
DSH390256S	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Neurosurgery Clinic	30 Hope Drive	Hershey	PA	Active
DSH390256T	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Breast Center	30 Hope Drive	Hershey	PA	Active
DSH390256U	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Orthopedics Clinic	30 Hope Drive	Hershey	PA	Active
DSH390256V	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Pediatric Bone & Joint	30 Hope Drive	Hershey	PA	Active
DSH390256W	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Cosmetic Surgery	5 Capital Drive	Harrisburg	PA	Terminated
DSH390256X	Child	DSH	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	Penn State Hershey Internal Medicine	35 Hope Drive	Hershey	PA	Terminated
DSH390256Y	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Neurology Clinic	30 Hope Drive	Hershey	PA	Active
DSH390256Z	Child	DSH	MILTON S. HERSHEY MEDICAL CENTER	Penn State Hershey Pediatrics	35 Hope Drive	Hershey	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Reuter, Taylor Shantel 340B Program Manager Penn State Milton S. Hershey Medical Center 7175310003-282085	Wetherill, Samuel VP Pharmacy Penn State Health 4109204494	3/14/2025 1:45 PM
Contacts	Authorizing Official	Update	Change Request	Ostasewski, Peter Carl VP & CFO Milton S. Hershey Medical Center 7175311355	Moyer, Tracy L Senior Vice President of Financial Operations Penn State Health 7175318477	3/13/2025 7:46 AM
Details	Entity Name	Update	Change Request	PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	MILTON S. HERSHEY MEDICAL CENTER	3/11/2025 6:52 AM
Details	Last Recertification Date	Update	Recertification	9/5/2023 2:55:41 PM	8/19/2024 1:40:04 PM	8/19/2024 1:40 PM
Addresses	Main Address	Update	Change Request	4000 Vine St Middletown, PA 17057	3100 Schoolhouse Rd Suite 100 Middletown, PA 17057	8/2/2024 11:38 AM
Details	Entity Subname	Update	Change Request	PSHMG Vine St Middletown	PSHMG Middletown Surgery Specialties	8/2/2024 11:38 AM
Contacts	Authorizing Official	Update	AO Change Request	Nickell, Julie B CFO Penn State Milton S. Hershey Medical Center 7175314631	Ostasewski, Peter Carl VP & CFO Milton S. Hershey Medical Center 7175311355	4/29/2024 1:38 PM
Contacts	Primary Contact	Update	PC Change Request	Granko, Robert Administrative Director of Pharmacy Milton S. Hershey Medical Center 7175318972	Reuter, Taylor Shantel 340B Program Manager Penn State Milton S. Hershey Medical Center 7175310003-282085	4/29/2024 7:09 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 11:27:50 AM	9/5/2023 2:55:41 PM	9/5/2023 2:55 PM
Contacts	Primary Contact	Update	Change Request	Lacroce, Vince Administrative Director of Pharmacy Milton S Hershey Medical Center 7175318972	Granko, Robert Administrative Director of Pharmacy Milton S. Hershey Medical Center 7175318972	7/26/2023 11:25 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 9:35:23 AM	8/30/2022 11:27:50 AM	8/30/2022 11:27 AM
Details	Last Recertification Date	Update	Recertification	9/1/2020 10:18:58 AM	8/24/2021 9:35:23 AM	8/24/2021 9:35 AM
Contacts	Authorizing Official	Update	Change Request	Tinch, Paula Marie CFO & SVP Finance, PSH Penn State Health 7175311788-7175311788	Nickell, Julie B CFO Penn State Milton S. Hershey Medical Center 7175314631	5/18/2021 4:39 PM
Contacts	Authorizing Official	Update	Profile Change Request	Tinch, Paula Marie CFO & SVP Finance, PSH Penn State Health 1717531178-7175311788	Tinch, Paula Marie CFO & SVP Finance, PSH Penn State Health 7175311788-7175311788	5/17/2021 7:46 AM
Contacts	Authorizing Official	Update	Change Request	Strucko, Eric Interim Chief Financial Officer Milton S. Hershey Medical Center 7175316122	Tinch, Paula Marie CFO & SVP Finance, PSH Penn State Health 1717531178-7175311788	9/15/2020 4:20 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1568435477	9/1/2020 10:18 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/1/2020 10:18 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1568435477 ( )		9/1/2020 10:18 AM
Details	Last Recertification Date	Update	Recertification	8/29/2019 3:30:55 PM	9/1/2020 10:18:58 AM	9/1/2020 10:18 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	1007653100027	1007653100005	12/4/2019 3:37 PM
Medicaid Billing	NPI: Number	Update	Change Request	1417094624	1568435477	12/4/2019 3:37 PM
Details	Last Recertification Date	Update	Recertification	8/24/2018 1:54:54 PM	8/29/2019 3:30:55 PM	8/29/2019 3:30 PM
Contacts	Authorizing Official	Update	Change Request	Swinko, Paul CHIEF FINANCIAL OFFICER Milton S Hershey Medical Center 7175318794	Strucko, Eric Interim Chief Financial Officer Milton S. Hershey Medical Center 7175316122	12/19/2018 12:17 PM
Contacts	Primary Contact	Update	Recertification	Lacroce, Vince Adminstrative Director of the Pharmacy Penn State Health Milton S. Hershey Medical Center 7175316378	Lacroce, Vince Administrative Director of Pharmacy Milton S Hershey Medical Center 7175318972	8/24/2018 1:54 PM
Details	Last Recertification Date	Update	Recertification	11/15/2017 3:21:17 PM	8/24/2018 1:54:54 PM	8/24/2018 1:54 PM
Details	Last Recertification Date	Update	Recertification	10/24/2017 1:25:03 PM	11/15/2017 3:21:17 PM	11/15/2017 3:21 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	10/24/2017 1:25:03 PM	10/24/2017 1:25 PM
Contacts	Primary Contact	Update		Lacroce, Vince Adminstrative Director of the Pharmacy 7175316378	Lacroce, Vince Adminstrative Director of the Pharmacy Penn State Health Milton S. Hershey Medical Center 7175316378	10/12/2017 2:41 PM
Contacts	Authorizing Official	Update		Swinko, Paul CHIEF FINANCIAL OFFICER 7175318794	Swinko, Paul CHIEF FINANCIAL OFFICER Milton S Hershey Medical Center 7175318794	10/5/2017 5:05 PM
Contacts	Authorizing Official	Update		Massini, Stephen CHIEF FINANCIAL OFFICER 7175316614	Swinko, Paul CHIEF FINANCIAL OFFICER 7175318794	7/17/2017 7:40 AM
Contacts	Signed By	Insert			Haley, Kevin Chief Financial Officer 7175316614	7/4/2017 6:56 AM
Contacts	Primary Contact	Insert			Lacroce, Vince Adminstrative Director of the Pharmacy 7175316378	7/4/2017 6:56 AM
Addresses	Main Address	Insert			4000 Vine St Middletown, PA 17057	7/4/2017 6:56 AM
Addresses	Billing Address	Insert			Penn State Milton S. Hershey Medical Center 500 University Dr Hershey, PA 17033	7/4/2017 6:56 AM
Contacts	Authorizing Official	Insert			Massini, Stephen CHIEF FINANCIAL OFFICER 7175316614	7/4/2017 6:55 AM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 8:12 AM
Details	Last Recertification Date	Update		8/21/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 5:20 PM
Medicaid Billing	Medicaid: Number	Update		1007653100036	1007653100027	11/18/2014 1:42 PM
Medicaid Billing	NPI: Number	Insert			1417094624	11/18/2014 1:42 PM
Details	Last Recertification Date	Update		8/27/2013 9:00:00 AM	8/21/2014 12:00:00 AM	8/21/2014 1:21 PM
Details	Last Recertification Date	Update			8/27/2013 9:00:00 AM	8/27/2013 9:00 AM
Dates	Participating Approval Date	Update			12/8/2011 12:00:00 AM	12/8/2011 2:40 PM
Details	State	Update		Pending	Active	12/8/2011 2:40 PM
Dates	Start Date	Update			12/8/2011 12:00:00 AM	12/8/2011 2:40 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH390256N	12/7/2011 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	11/30/2011 7:23 PM
Medicaid Billing	Medicaid: Number	Insert			1007653100036	11/30/2011 7:23 PM
Medicaid Billing	Medicaid: State	Insert			PA	11/30/2011 7:23 PM
Details	Last Recertification Date	Insert				11/30/2011 7:23 PM
Details	Grant Number	Insert				11/30/2011 7:23 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	11/30/2011 7:23 PM
Details	Is Authorizing Official EHB Data	Insert				11/30/2011 7:23 PM
Dates	Last Date That 340B Drugs Purchased	Insert				11/30/2011 7:23 PM
Details	Medicare Provider Number	Insert			390256	11/30/2011 7:23 PM
Details	Entity Name	Insert			PENN STATE - MILTON S. HERSHEY MEDICAL CENTER	11/30/2011 7:23 PM
Details	Program Code	Insert			DSH	11/30/2011 7:23 PM
Details	Entity Subname	Insert			PSHMG Vine St Middletown	11/30/2011 7:23 PM
Dates	Participating Approval Date	Insert				11/30/2011 7:23 PM
Details	State	Insert			Pending	11/30/2011 7:23 PM
Dates	Registration Date	Insert			11/30/2011 12:00:00 AM	11/30/2011 7:23 PM
Dates	Signed By Date	Insert			11/30/2011 12:00:00 AM	11/30/2011 7:23 PM
Dates	Start Date	Insert				11/30/2011 7:23 PM
Terminations	Termination Comments	Insert				11/30/2011 7:23 PM
Terminations	Termination Date	Insert				11/30/2011 7:23 PM
Terminations	Termination Effective Date	Insert				11/30/2011 7:23 PM
Terminations	Termination Reason	Insert				11/30/2011 7:23 PM