Covered Entity Details

DSH340090G Johnston Health Services Corporation (Active) - information as of 4/25/2025 6:31:51 PM

Main Details

Name

Johnston Health Services Corporation

Subdivision Name

Johnston Medical Center - Clayton Emergency Department

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340090G

Medicare Provider Number

340090

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

5/30/2012

Participating Start Date

1/1/2013

Participating Approval Date

12/14/2012

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Johnston Health Services Corporation
Ruth L Marler, COO/CNO
(919) 938-7383

Primary Contact

Johnston Health Services Corporation
David Willoughby, Director of Pharmacy Services
(919) 938-7288

Addresses

Street Address

2138 NC Hwy 42 W
Clayton, NC 27520

Billing Address

Johnston Health Services Corporation
509 N Brightleaf Blvd
Smithfield, NC 27577

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
NC	340090	1619911104,1780628354
SC		1619911104,1780628354
VA		1619911104,1780628354

Shipping Addresses

Shipping Address 1

Johnston Medical Center- Clayton
2138 NC Hwy 42 W
Clayton, NC 27520

Shipping Address 2

UNC Shared Services Center Pharmacy
4400 Emperor Boulevard
Durham, NC 27703

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
DSH340090D	Child	DSH	Johnston Health Services Corporation	JOHNSTON CANCER CENTER	514 N. BRIGHTLEAF BLVD	SMITHFIELD	NC	Active
DSH340090F	Child	DSH	Johnston Health Services Corporation	Johnston Hematology/Oncology-Clayton	2076 NC Hwy 42 W	Clayton	NC	Active
DSH340090G	Child	DSH	Johnston Health Services Corporation	Johnston Medical Center - Clayton Emergency Department	2138 NC Hwy 42 W	Clayton	NC	Active
DSH340090H	Child	DSH	Johnston Health Services Corporation	Johnston Medical Center- Clayton Operating Room	2138 NC Hwy 42 W	Clayton	NC	Active
DSH340090J	Child	DSH	Johnston Health Services Corporation	Johnston Medical Center-Clayton Radiology	2138 NC Hwy 42 W	Clayton	NC	Active
DSH340090K	Child	DSH	Johnston Health Services Corporation	JOHNSTON HEALTH AMBULATORY IMAGING	514 N. BRIGHTLEAF BLVD	SMITHFIELD	NC	Active
DSH340090L	Child	DSH	Johnston Health Services Corporation	JOHNSTON HEALTH CARDIOPULMONARY REH	514 N. BRIGHTLEAF BLVD	SMITHFIELD	NC	Active
DSH340090M	Child	DSH	Johnston Health Services Corporation	JOHNSTON HEALTH THERAPEUTIC WOUND CENTER	514 N BRIGHTLEAF BOULEVARD	SMITHFIELD	NC	Terminated
DSH340090N	Child	DSH	Johnston Health Services Corporation	Johnston Health - Clayton / Observation - 3rd Floor Bed Tower	2138 NC Hwy 42 W	Clayton	NC	Terminated
DSH340090P	Child	DSH	Johnston Health Services Corporation	Johnston Health - Clayton / Observation - 2nd Floor Bed Tower	2138 NC Hwy 42 W	Clayton	NC	Terminated
DSH340090Q	Child	DSH	Johnston Health Services Corporation	Johnston Health - Clayton / Labor and Delivery	2138 NC Hwy 42 W	Clayton	NC	Active
DSH340090R	Child	DSH	Johnston Health Services Corporation	Johnston Health - Clayton / Obstetrics	2138 NC Hwy 42 W	Clayton	NC	Terminated
DSH340090S	Child	DSH	Johnston Health Services Corporation	Johnston Health - Clayton / Respiratory Care	2138 NC Hwy 42 W	Clayton	NC	Terminated
DSH340090T	Child	DSH	Johnston Health Services Corporation	Johnston Health-Clayton / Radiology-Diagnostic	2138 NC Hwy 42 W	Clayton	NC	Active
DSH340090U	Child	DSH	Johnston Health Services Corporation	Johnston Health - Clayton / MRI	2138 NC Hwy 42 W	Clayton	NC	Active
DSH340090V	Child	DSH	Johnston Health Services Corporation	Johnston Health -Clayton / Interventional Radiology	2138 NC Hwy 42 W	Clayton	NC	Active
DSH340090W	Child	DSH	Johnston Health Services Corporation	Johnston Health- Clayton / Cardiology	2138 NC Hwy 42 W	Clayton	NC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/31/2023 2:49:57 PM	9/5/2024 11:34:14 AM	9/5/2024 11:34 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 4:51:15 PM	8/31/2023 2:49:57 PM	8/31/2023 2:49 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	3400090 (NC)		6/22/2023 3:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/22/2023 3:37 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		340090	6/22/2023 3:37 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		NC	6/22/2023 3:37 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780628354	6/22/2023 3:37 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		NC	6/22/2023 3:37 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619911104	6/22/2023 3:37 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	6/22/2023 3:37 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780628354	6/22/2023 3:37 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	6/22/2023 3:37 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619911104	6/22/2023 3:37 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/22/2023 3:37 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1780628354	6/22/2023 3:37 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/22/2023 3:37 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 11:19:15 AM	9/8/2022 4:51:15 PM	9/8/2022 4:51 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	182839 (VA)		9/9/2021 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	30215338 (SC)		9/9/2021 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	110139655A (MA)		9/9/2021 11:19 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	092712100 (FL)		9/9/2021 11:19 AM
Details	Last Recertification Date	Update	Recertification	9/4/2020 9:55:10 AM	9/9/2021 11:19:15 AM	9/9/2021 11:19 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1619911104	9/4/2020 9:55 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2020 9:55 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1619911104 ( )		9/4/2020 9:55 AM
Details	Last Recertification Date	Update	Recertification	9/3/2019 3:08:24 PM	9/4/2020 9:55:10 AM	9/4/2020 9:55 AM
Contacts	Authorizing Official	Update	Profile Change Request	Marler, Ruth L COO/CNO Jhonston Health 9199387383	Marler, Ruth L COO/CNO Johnston Health Services Corporation 9199387383	12/16/2019 11:20 AM
Contacts	Authorizing Official	Update	Change Request	Elliott, Charles W CEO Johnston Health Services Corporation 9199387111	Marler, Ruth L COO/CNO Jhonston Health 9199387383	12/6/2019 7:01 AM
Details	Last Recertification Date	Update	Recertification	9/4/2018 11:16:15 AM	9/3/2019 3:08:24 PM	9/3/2019 3:08 PM
Contacts	Authorizing Official	Update	Profile Change Request	Elliott, Charles W CEO Johnston Health 9199387111	Elliott, Charles W CEO Johnston Health Services Corporation 9199387111	11/16/2018 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/16/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		182839	11/16/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	11/16/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/16/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		30215338	11/16/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	11/16/2018 3:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/16/2018 3:32 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110139655A	11/16/2018 3:32 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	11/16/2018 3:32 PM
Details	Last Recertification Date	Update	Recertification	11/18/2017 12:28:44 PM	9/4/2018 11:16:15 AM	9/4/2018 11:16 AM
Addresses	Billing Address	Insert	Recertification		Johnston Health Services Corporation 509 N Brightleaf Blvd Smithfield, NC 27577	11/18/2017 12:28 PM
Addresses	Shipping Address	Insert	Recertification		UNC Shared Services Center Pharmacy 4400 Emperor Boulevard Durham, NC 27703	11/18/2017 12:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	11/18/2017 12:28 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		092712100	11/18/2017 12:28 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	11/18/2017 12:28 PM
Details	Last Recertification Date	Update	Recertification	8/30/2016 12:00:00 AM	11/18/2017 12:28:44 PM	11/18/2017 12:28 PM
Contacts	Authorizing Official	Insert	Change Request		Elliott, Charles W CEO Johnston Health 9199387111	10/19/2017 7:48 PM
Contacts	Primary Contact	Update		Willoughby, David Director of Pharmacy Services 9199387288	Willoughby, David Director of Pharmacy Services Johnston Health Services Corporation 9199387288	10/11/2017 3:44 PM
Contacts	Signed By	Insert			Elliott Jr., Charles W. CEO 9199387111	2/24/2017 2:33 PM
Contacts	Primary Contact	Update		Garris, Greg Director Pharmacy Services 9199387288	Willoughby, David Director of Pharmacy Services 9199387288	2/24/2017 2:33 PM
Addresses	Main Address	Insert			2138 NC Hwy 42 W Clayton, NC 27520	2/24/2017 2:33 PM
Addresses	Shipping Address	Insert			Johnston Medical Center- Clayton 2138 NC Hwy 42 W Clayton, NC 27520	2/24/2017 2:33 PM
Details	Last Recertification Date	Update		8/13/2015 12:00:00 AM	8/30/2016 12:00:00 AM	8/30/2016 1:49 PM
Contacts	Primary Contact	Insert			Garris, Greg Director Pharmacy Services 9199387288	8/13/2015 5:51 PM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/13/2015 12:00:00 AM	8/13/2015 5:51 PM
Details	Last Recertification Date	Update		9/6/2013 12:00:00 AM	8/7/2014 12:00:00 AM	8/7/2014 2:19 PM
Details	Last Recertification Date	Update		9/6/2013 1:29:34 PM	9/6/2013 12:00:00 AM	3/25/2014 10:09 AM
Details	Entity Name	Update		JOHNSTON MEMORIAL HOSPITAL	Johnston Health Services Corporation	3/25/2014 10:09 AM
Details	Last Recertification Date	Update			9/6/2013 1:29:34 PM	9/6/2013 1:29 PM
Details	340B ID	Update		IS-DSH340090B	DSH340090G	12/14/2012 2:07 PM
Dates	Participating Approval Date	Update			12/14/2012 12:00:00 AM	12/14/2012 2:07 PM
Details	State	Update		Pending	Active	12/14/2012 2:07 PM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	12/14/2012 2:07 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-DSH340090B	12/14/2012 12:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/30/2012 11:22 AM
Medicaid Billing	Medicaid: Number	Insert			3400090	5/30/2012 11:22 AM
Medicaid Billing	Medicaid: State	Insert			NC	5/30/2012 11:22 AM
Medicaid Billing	NPI: Number	Insert			1619911104	5/30/2012 11:22 AM
Details	Last Recertification Date	Insert				5/30/2012 11:22 AM
Details	Grant Number	Insert				5/30/2012 11:22 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	5/30/2012 11:22 AM
Details	Is Authorizing Official EHB Data	Insert				5/30/2012 11:22 AM
Dates	Last Date That 340B Drugs Purchased	Insert				5/30/2012 11:22 AM
Details	Medicare Provider Number	Insert			340090	5/30/2012 11:22 AM
Details	Entity Name	Insert			JOHNSTON MEMORIAL HOSPITAL	5/30/2012 11:22 AM
Details	Program Code	Insert			DSH	5/30/2012 11:22 AM
Details	Entity Subname	Insert			Johnston Medical Center - Clayton Emergency Department	5/30/2012 11:22 AM
Dates	Participating Approval Date	Insert				5/30/2012 11:22 AM
Details	State	Insert			Pending	5/30/2012 11:22 AM
Dates	Registration Date	Insert			5/30/2012 12:00:00 AM	5/30/2012 11:22 AM
Dates	Signed By Date	Insert			5/30/2012 12:00:00 AM	5/30/2012 11:22 AM
Dates	Start Date	Insert				5/30/2012 11:22 AM
Terminations	Termination Comments	Insert				5/30/2012 11:22 AM
Terminations	Termination Date	Insert				5/30/2012 11:22 AM
Terminations	Termination Effective Date	Insert				5/30/2012 11:22 AM
Terminations	Termination Reason	Insert				5/30/2012 11:22 AM