Covered Entity Details

DSH340003A NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY (Terminated) - information as of 5/1/2025 11:50:50 PM

Main Details

Name

NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY

Subdivision Name

REVIVAL PAIN MANAGEMENT

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH340003A

Medicare Provider Number

340003

Outpatient Facility Provider Number

232278

Additional Details

Current Program Status

Terminated

Registration Date

4/14/2014

Participating Start Date

7/1/2014

Participating Approval Date

5/22/2014

Last Recertification Date

9/5/2018

Termination Date
Termination Reason

4/1/2019
DSH percentage below statutory minimum

Contacts

Authorizing Official

Northern Hospital
Robin Hodgin, VP Patient Care Services
(336) 719-7019

Primary Contact

Northern Hospital of Surry County
DARRELL ESTES, DIRECTOR OF PHARMACY
(336) 719-7120

Addresses

Street Address

110 DUTCHMAN'S COURT
ELKIN, NC 28621

Billing Address
Same as Street Address

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	1225379910
		1225379910

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
DSH340003A	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	REVIVAL PAIN MANAGEMENT	110 DUTCHMAN'S COURT	ELKIN	NC	Terminated
DSH340003B	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	HOSPITALISTS OF MOUNT AIRY	830 ROCKFORD STREET	MOUNT AIRY	NC	Terminated
DSH340003C	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	SURRY MEDICAL SPECIALISTS	708 S. SOUTH STREET	MOUNT AIRY	NC	Terminated
DSH340003D	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	MOUNT AIRY OB-GYN	510 S. SOUTH STREET	MOUNT AIRY	NC	Terminated
DSH340003E	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	NORTHERN PEDIATRICS	100 NORTH POINTE BLVD	MOUNT AIRY	NC	Terminated
DSH340003F	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	SURRY UROLOGICAL ASSOCIATES	423 S. SOUTH STREET	MOUNT AIRY	NC	Terminated
DSH340003G	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	SURRY SURGICAL ASSOCIATES	708 S. SOUTH STREET SUITE 100	MOUNT AIRY	NC	Terminated
DSH340003H	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	BLUE RIDGE BONE AND JOINT	314 S. SOUTH STREET	MOUNT AIRY	NC	Terminated
DSH340003J	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	WOUND CARE CENTER	314 S SOUTH STREET	MOUNT AIRY	NC	Terminated
DSH340003K	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	NORTH STATE BONE	314 S. SOUTH STREET	MOUNT AIRY	NC	Terminated
DSH340003L	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	FAMILY MEDICINE	280 NORTH POINTE BLVD	MOUNT AIRY	NC	Terminated
DSH340003M	Child	DSH	NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	NORTHERN GASTROENTEROLOGY	708 S. SOUTH STREET SUITE 100	MOUNT AIRY	NC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/28/2019 12:00:00 AM	2/28/2019 4:05 PM
Details	State	Update	Termination Request	Active	To Be Terminated	2/28/2019 4:05 PM
Terminations	Termination Date	Update	Termination Request		4/1/2019 12:00:00 AM	2/28/2019 4:05 PM
Terminations	Termination Effective Date	Update	Termination Request		3/1/2019 12:00:00 AM	2/28/2019 4:05 PM
Terminations	Termination Reason	Update	Termination Request		DSH percentage below statutory minimum	2/28/2019 4:05 PM
Details	Last Recertification Date	Update	Recertification	11/3/2017 3:39:07 PM	9/5/2018 12:21:43 PM	9/5/2018 12:21 PM
Contacts	Primary Contact	Update	Change Request	WILSON, MICHELLE DIRECTOR OF PHARMACY Northern Hospital 3367197120	ESTES, DARRELL DIRECTOR OF PHARMACY Northern Hospital of Surry County 3367197120	8/10/2018 11:29 AM
Contacts	Primary Contact	Update	Recertification	ESTES, DARRELL DIRECTOR OF PHARMACY 3367197120	WILSON, MICHELLE DIRECTOR OF PHARMACY Northern Hospital 3367197120	11/3/2017 3:39 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/3/2017 3:39:07 PM	11/3/2017 3:39 PM
Contacts	Authorizing Official	Update		Hodgin, Robin VP Patient Care Services 3367197019	Hodgin, Robin VP Patient Care Services Northern Hospital 3367197019	9/29/2017 3:01 PM
Contacts	Signed By	Update		Hodgin, Robin VP Patient Care Services 3367197019	Hodgin, Robin VP Patient Care Services Northern Hospital 3367197019	9/29/2017 3:01 PM
Addresses	Main Address	Insert			110 DUTCHMAN'S COURT ELKIN, NC 28621	6/9/2017 3:46 PM
Contacts	Authorizing Official	Insert			Hodgin, Robin VP Patient Care Services 3367197019	6/9/2017 3:46 PM
Contacts	Signed By	Insert			Hodgin, Robin VP Patient Care Services 3367197019	6/9/2017 3:46 PM
Contacts	Primary Contact	Insert			ESTES, DARRELL DIRECTOR OF PHARMACY 3367197120	6/9/2017 3:46 PM
Details	Last Recertification Date	Update		8/11/2015 12:00:00 AM	8/17/2016 12:00:00 AM	8/17/2016 10:18 AM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/11/2015 8:51 AM
Details	Last Recertification Date	Update		8/11/2014 12:00:00 AM	8/11/2015 12:00:00 AM	8/11/2015 8:51 AM
Details	Last Recertification Date	Update			8/11/2014 12:00:00 AM	8/11/2014 10:12 AM
Dates	Participating Approval Date	Update			5/22/2014 12:00:00 AM	5/22/2014 5:37 PM
Details	State	Update		Pending	Active	5/22/2014 5:37 PM
Dates	Start Date	Update			7/1/2014 12:00:00 AM	5/22/2014 5:37 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH340003A	4/24/2014 5:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	4/14/2014 12:14 PM
Medicaid Billing	Medicaid: Number	Insert			1225379910	4/14/2014 12:14 PM
Medicaid Billing	Medicaid: State	Insert			NC	4/14/2014 12:14 PM
Medicaid Billing	NPI: Number	Insert			1225379910	4/14/2014 12:14 PM
Details	Last Recertification Date	Insert				4/14/2014 12:14 PM
Details	Grant Number	Insert				4/14/2014 12:14 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/14/2014 12:14 PM
Details	Is Authorizing Official EHB Data	Insert				4/14/2014 12:14 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/14/2014 12:14 PM
Details	Medicare Provider Number	Insert			340003	4/14/2014 12:14 PM
Details	Entity Name	Insert			NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY	4/14/2014 12:14 PM
Details	Program Code	Insert			DSH	4/14/2014 12:14 PM
Details	Entity Subname	Insert			REVIVAL PAIN MANAGEMENT	4/14/2014 12:14 PM
Dates	Participating Approval Date	Insert				4/14/2014 12:14 PM
Details	State	Insert			Pending	4/14/2014 12:14 PM
Dates	Registration Date	Insert			4/14/2014 12:00:00 AM	4/14/2014 12:14 PM
Dates	Signed By Date	Insert			4/14/2014 12:00:00 AM	4/14/2014 12:14 PM
Dates	Start Date	Insert				4/14/2014 12:14 PM
Terminations	Termination Comments	Insert				4/14/2014 12:14 PM
Terminations	Termination Date	Insert				4/14/2014 12:14 PM
Terminations	Termination Effective Date	Insert				4/14/2014 12:14 PM
Terminations	Termination Reason	Insert				4/14/2014 12:14 PM