| Details | State | Update | | To Be Terminated | Terminated | 7/1/2024 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 3/31/2024 12:00:00 AM | 4/12/2024 9:19 AM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 4/12/2024 9:19 AM |
| Terminations | Termination Date | Update | Termination Request | | 7/1/2024 12:00:00 AM | 4/12/2024 9:19 AM |
| Terminations | Termination Effective Date | Update | Termination Request | | 4/1/2024 12:00:00 AM | 4/12/2024 9:19 AM |
| Terminations | Termination Reason | Update | Termination Request | | Hospital Outpatient facility no longer eligible | 4/12/2024 9:19 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Willman, Diana
Pharmacy Director
Bon Secours Mercy Health
8047655093 | Willman, Diana
Pharmacy Director
Bon Secours Mercy Health
7573982192 | 10/17/2023 1:46 PM |
| Contacts | Primary Contact | Update | Change Request | Fairfield, Autumn
340B Manager
Bon Secours Mercy Health
2702174090 | Willman, Diana
Pharmacy Director
Bon Secours Mercy Health
8047655093 | 9/18/2023 10:32 AM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2022 10:33:36 AM | 8/24/2023 3:18:16 PM | 8/24/2023 3:18 PM |
| Contacts | Primary Contact | Update | Change Request | Bouldin, Danielle
Director of Pharmacy
Bon Secours
7573982192 | Fairfield, Autumn
340B Manager
Bon Secours Mercy Health
2702174090 | 7/26/2023 6:56 AM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2021 12:11:48 PM | 8/31/2022 10:33:36 AM | 8/31/2022 10:33 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Simmerman, John Carr
CFO
MaryView Medical Center
7573982133 | Haynes, Jonathan Lee
Hampton Roads Market CFO
Bon Secours Mercy Health
5402702809 | 7/29/2022 7:23 AM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2020 2:30:33 PM | 8/23/2021 12:11:48 PM | 8/23/2021 12:11 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 8/25/2020 2:30 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 490017 | 8/25/2020 2:30 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | VA | 8/25/2020 2:30 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | VA | 8/25/2020 2:30 PM |
| Contacts | Primary Contact | Update | Recertification | Deal, Coley W
340B Program Manager
Bon Secours
8042214837 | Bouldin, Danielle
Director of Pharmacy
Bon Secours
7573982192 | 8/25/2020 2:30 PM |
| Details | Last Recertification Date | Update | Recertification | 9/4/2019 1:50:58 PM | 8/25/2020 2:30:33 PM | 8/25/2020 2:30 PM |
| Contacts | Authorizing Official | Update | Change Request | Quiriconi, Stephan
Senior VP of Finance
Bon Secours Mercy Health System
8042818301 | Simmerman, John Carr
CFO
MaryView Medical Center
7573982133 | 5/26/2020 12:05 PM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2018 1:34:29 PM | 9/4/2019 1:50:58 PM | 9/4/2019 1:50 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Gaden, Paul
CEO
Maryview Medical Center
7573982122 | Quiriconi, Stephan
Senior VP of Finance
Bon Secours Mercy Health System
8042818301 | 8/22/2019 9:51 AM |
| Details | Entity Subname | Update | Change Request | Western Branch Family Practice | Western Branch Primary Care | 4/17/2019 8:16 AM |
| Contacts | Primary Contact | Update | Recertification | Deal, Coley
Bon Secours 340B Manager
Bon Secours Health System
8042214837 | Deal, Coley W
340B Program Manager
Bon Secours
8042214837 | 8/27/2018 1:34 PM |
| Details | Last Recertification Date | Update | Recertification | 11/28/2017 3:38:13 PM | 8/27/2018 1:34:29 PM | 8/27/2018 1:34 PM |
| Contacts | Authorizing Official | Update | Change Request | Bartlett, Cindy K.
VP Corporate Responsibility
Bon Secours Health System
7576735835 | Gaden, Paul
CEO
Maryview Medical Center
7573982122 | 4/12/2018 2:59 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1750399192 | 11/28/2017 3:38 PM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2016 12:00:00 AM | 11/28/2017 3:38:13 PM | 11/28/2017 3:38 PM |
| Contacts | Primary Contact | Update | Recertification | Stoneburner, Robert
Administrative Director- Pharmacy Services
7573982407 | Deal, Coley
Bon Secours 340B Manager
Bon Secours Health System
8042214837 | 11/28/2017 3:24 PM |
| Addresses | Main Address | Update | OPA Edit |
3253 Taylor Road
Suite 200
Chesapeake, VA 23321 |
2613 Taylor Road
Suite 201
Chesapeake, VA 23321 | 10/26/2017 10:33 AM |
| Contacts | Authorizing Official | Update | | Bartlett, Cindy K.
VP Corporate Responsibility
7576735835 | Bartlett, Cindy K.
VP Corporate Responsibility
Bon Secours Health System
7576735835 | 9/27/2017 5:04 PM |
| Contacts | Signed By | Insert | | | Oddis, Joseph M.
CEO
7573982135 | 5/4/2017 9:59 AM |
| Contacts | Primary Contact | Insert | | | Stoneburner, Robert
Administrative Director- Pharmacy Services
7573982407 | 5/4/2017 9:59 AM |
| Contacts | Authorizing Official | Insert | | | Bartlett, Cindy K.
VP Corporate Responsibility
7576735835 | 5/4/2017 9:59 AM |
| Addresses | Main Address | Insert | | |
3253 Taylor Road
Suite 200
Chesapeake, VA 23321 | 5/4/2017 9:57 AM |
| Addresses | Billing Address | Insert | | | Bon Secours Maryview Medical Center
3636 High Street
Portsmouth, VA 23707 | 5/4/2017 9:57 AM |
| Addresses | Shipping Address | Insert | | | Bon Secours Maryview Medical Center
3636 High Street
Portsmouth, VA 23707 | 5/4/2017 9:57 AM |
| Details | Last Recertification Date | Update | | 8/14/2015 12:00:00 AM | 8/26/2016 12:00:00 AM | 8/26/2016 5:18 PM |
| Details | Last Recertification Date | Update | | 8/18/2014 12:00:00 AM | 8/14/2015 12:00:00 AM | 8/14/2015 1:21 PM |
| Details | Last Recertification Date | Update | | 8/23/2013 12:00:00 AM | 8/18/2014 12:00:00 AM | 8/18/2014 2:58 PM |
| Details | Last Recertification Date | Update | | | 8/23/2013 12:00:00 AM | 8/23/2013 10:39 AM |
| Details | 340B ID | Update | | ISJMDSH490017G | DSH490017G | 3/11/2013 5:55 PM |
| Dates | Participating Approval Date | Update | | | 3/11/2013 12:00:00 AM | 3/11/2013 5:55 PM |
| Details | State | Update | | Pending | Active | 3/11/2013 5:55 PM |
| Dates | Start Date | Update | | | 4/1/2013 12:00:00 AM | 3/11/2013 5:55 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | ISJMDSH490017G | 2/11/2013 3:37 PM |
| Details | Last Recertification Date | Insert | | | | 1/14/2013 3:59 PM |
| Details | Grant Number | Insert | | | | 1/14/2013 3:59 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 1/14/2013 3:59 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 1/14/2013 3:59 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/14/2013 3:59 PM |
| Details | Medicare Provider Number | Insert | | | 490017 | 1/14/2013 3:59 PM |
| Details | Entity Name | Insert | | | BON SECOURS MARYVIEW MEDICAL CENTER | 1/14/2013 3:59 PM |
| Details | Program Code | Insert | | | DSH | 1/14/2013 3:59 PM |
| Details | Entity Subname | Insert | | | Western Branch Family Practice | 1/14/2013 3:59 PM |
| Dates | Participating Approval Date | Insert | | | | 1/14/2013 3:59 PM |
| Details | State | Insert | | | Pending | 1/14/2013 3:59 PM |
| Dates | Registration Date | Insert | | | 1/14/2013 12:00:00 AM | 1/14/2013 3:59 PM |
| Dates | Signed By Date | Insert | | | 1/14/2013 12:00:00 AM | 1/14/2013 3:59 PM |
| Dates | Start Date | Insert | | | | 1/14/2013 3:59 PM |
| Terminations | Termination Comments | Insert | | | | 1/14/2013 3:59 PM |
| Terminations | Termination Date | Insert | | | | 1/14/2013 3:59 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/14/2013 3:59 PM |
| Terminations | Termination Reason | Insert | | | | 1/14/2013 3:59 PM |