Covered Entity Details

DSH440063B JOHNSON CITY MEDICAL CENTER (Terminated) - information as of 5/17/2025 10:56:29 PM

Main Details

Name

JOHNSON CITY MEDICAL CENTER

Subdivision Name

Regional Cancer Center @ Johnson City Medical Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH440063B

Medicare Provider Number

440063

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/10/2013

Participating Start Date

1/1/2014

Participating Approval Date

12/13/2013

Last Recertification Date

8/7/2015

Termination Date
Termination Reason

10/1/2016
Site closure

Contacts

Authorizing Official

Mountain States Health Alliance
Shane Hilton, VP/CFO - Market Operations
(423) 302-3467

Primary Contact

MSHA
Trish Tanner, AVP Pharmacy Services
(423) 302-3532

Addresses

Street Address

2205 Pavilion Drive
Suite 101
Kingsport, TN 37660-4641

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
12/3/13 I'm not sure that AO/SBO is at high enough level, pls chk 12/4/13: Changed AO to Chief Financial officer.	12/04/2013
12/3/13 I'm not sure that AO/SBO is at high enough level, pls chk	12/03/2013

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

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
DSH440063A	Child	DSH	JOHNSON CITY MEDICAL CENTER	Ballad Health Cancer Care a Department of Johnson City Medical Center	1 PROFESSIONAL PARK DRIVE	JOHNSON CITY	TN	Active
DSH440063B	Child	DSH	JOHNSON CITY MEDICAL CENTER	Regional Cancer Center @ Johnson City Medical Center	2205 Pavilion Drive	Kingsport	TN	Terminated

History

Section	Field	Action	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Tanner, Trish AVP Pharmacy Services 4233023532	Tanner, Trish AVP Pharmacy Services MSHA 4233023532	10/11/2017 4:14 PM
Contacts	Signed By	Update	Tanner, Trish AVP Pharmacy Services 4233023532	Tanner, Trish AVP Pharmacy Services MSHA 4233023532	10/11/2017 4:14 PM
Contacts	Authorizing Official	Update	Hilton, Shane VP/CFO - Market Operations 4233023467	Hilton, Shane VP/CFO - Market Operations Mountain States Health Alliance 4233023467	10/10/2017 10:53 AM
Contacts	Authorizing Official	Insert		Hilton, Shane VP/CFO - Market Operations 4233023467	7/18/2017 3:43 PM
Contacts	Primary Contact	Insert		Tanner, Trish AVP Pharmacy Services 4233023532	6/6/2017 2:27 PM
Contacts	Signed By	Insert		Tanner, Trish AVP Pharmacy Services 4233023532	6/6/2017 2:27 PM
Addresses	Main Address	Insert		2205 Pavilion Drive Suite 101 Kingsport, TN 37660-4641	7/18/2016 8:04 AM
Dates	Last Date That 340B Drugs Purchased	Update		6/29/2016 12:00:00 AM	7/18/2016 8:04 AM
Details	State	Update	Active	Terminated	7/18/2016 8:04 AM
Terminations	Termination Comments	Update		Site left Johnson City Medical Center and was rolled up under another facility.	7/18/2016 8:04 AM
Terminations	Termination Date	Update		10/1/2016 12:00:00 AM	7/18/2016 8:04 AM
Terminations	Termination Effective Date	Update		7/1/2016 12:00:00 AM	7/18/2016 8:04 AM
Terminations	Termination Reason	Update		Site closure	7/18/2016 8:04 AM
Details	Last Recertification Date	Update	8/7/2014 12:00:00 AM	8/7/2015 12:00:00 AM	8/10/2015 9:20 AM
Details	Entity Subname	Update	Regional Cancer Center @ Kingsport	Regional Cancer Center @ Johnson City Medical Center	1/6/2015 7:33 AM
Details	Last Recertification Date	Update		8/7/2014 12:00:00 AM	8/7/2014 2:36 PM
Dates	Participating Approval Date	Update		12/13/2013 12:00:00 AM	12/13/2013 7:05 AM
Details	State	Update	Pending	Active	12/13/2013 7:05 AM
Dates	Start Date	Update		1/1/2014 12:00:00 AM	12/13/2013 7:05 AM
Details	Comments Public	Insert		12/3/13 I'm not sure that AO/SBO is at high enough level, pls chk 12/4/13: Changed AO to Chief Financial officer.	12/4/2013 2:16 PM
Details	Comments Public	Insert		12/3/13 I'm not sure that AO/SBO is at high enough level, pls chk	12/3/2013 2:13 PM
Details	340B ID	Update	OUTPATIENT_ONLINE_REG	DSH440063B	12/2/2013 4:44 PM
Details	Last Recertification Date	Insert			10/10/2013 10:13 AM
Details	Grant Number	Insert			10/10/2013 10:13 AM
Details	340B ID	Insert		OUTPATIENT_ONLINE_REG	10/10/2013 10:13 AM
Details	Is Authorizing Official EHB Data	Insert			10/10/2013 10:13 AM
Dates	Last Date That 340B Drugs Purchased	Insert			10/10/2013 10:13 AM
Details	Medicare Provider Number	Insert		440063	10/10/2013 10:13 AM
Details	Entity Name	Insert		JOHNSON CITY MEDICAL CENTER	10/10/2013 10:13 AM
Details	Program Code	Insert		DSH	10/10/2013 10:13 AM
Details	Entity Subname	Insert		Regional Cancer Center @ Kingsport	10/10/2013 10:13 AM
Dates	Participating Approval Date	Insert			10/10/2013 10:13 AM
Details	State	Insert		Pending	10/10/2013 10:13 AM
Dates	Registration Date	Insert		10/10/2013 12:00:00 AM	10/10/2013 10:13 AM
Dates	Signed By Date	Insert		10/10/2013 12:00:00 AM	10/10/2013 10:13 AM
Dates	Start Date	Insert			10/10/2013 10:13 AM
Terminations	Termination Comments	Insert			10/10/2013 10:13 AM
Terminations	Termination Date	Insert			10/10/2013 10:13 AM
Terminations	Termination Effective Date	Insert			10/10/2013 10:13 AM
Terminations	Termination Reason	Insert			10/10/2013 10:13 AM