Covered Entity Details

CHC26576-00 Dayton Health Center dba Five Rivers Health Centers (Active) - information as of 4/30/2025 10:56:07 PM

Main Details

Name

Dayton Health Center dba Five Rivers Health Centers

Subdivision Name

Five Rivers Health Centers Edgemont Campus

Type

HRSA-Funded Health Center

Site ID

BPS-H80-033602

340B ID

CHC26576-00

Grant Number

H80CS26576

Additional Details

Current Program Status

Active

Registration Date

4/14/2014

Participating Start Date

7/1/2014

Participating Approval Date

4/30/2014

Last Recertification Date

2/12/2025

Contacts

Authorizing Official

Five Rivers Health Centers
Gina McFarlane-El, CEO
(937) 281-5940

Primary Contact

Five Rivers Health Centers
John Howard Tomlin, Pharmacy Director
(937) 281-6825

Addresses

Street Address

721 Miami Chapel Road
Dayton, OH 45417

Billing Address

Five Rivers Health Centers Edgemont Campus
721 Miami Chapel Road
Dayton, OH 45417

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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
OH	0490753,0086072	1891466280,1497190771,1710530886

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/12/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/12/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/12/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/12/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/12/2024	10/01/2024		10/01/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/12/2024	10/01/2024		10/01/2024
Contract Detail	BARR'S PHARMACY	28 W. MAIN ST		XENIA	OH	45385	01/26/2023	02/06/2023		02/06/2023
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/12/2024	10/01/2024		10/01/2024
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/12/2024	10/01/2024		10/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/12/2024	10/01/2024		10/01/2024
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/12/2024	10/01/2024		10/01/2024
Contract Detail	KROGER PHARMACY #014836	3520 WEST SIEBENTHALER AVENUE		DAYTON	OH	45406	04/07/2015	07/01/2015	01/07/2016	02/05/2016
Contract Detail	KROGER PHARMACY #765	601 WOODMAN DR		DAYTON	OH	45431	04/07/2015	07/01/2015	01/07/2016	02/05/2016
Contract Detail	MIAMI VALLEY PHARMACY		ONE WYOMING STREET	DAYTON	OH	45409	10/01/2014	10/03/2014	01/12/2017	01/12/2017
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03411	200 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	01/15/2018	04/01/2018		01/15/2018
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03447	4901 N MAIN ST	DAYTON	OH	45415	01/15/2018	04/01/2018		01/15/2018
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06141	1001 E. MAIN ST.	TROTWOOD	OH	45426	01/15/2018	04/01/2018		01/15/2018
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03080	4996 BRANDT PIKE	HUBER HEIGHTS	OH	45424	04/12/2019	07/01/2019		07/01/2019
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03404	35 S. ALLISON AVE.	XENIA	OH	45385	04/12/2019	07/01/2019		07/01/2019
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03420	1410 E DOROTHY LN	KETTERING	OH	45429	04/12/2019	07/01/2019		07/01/2019
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03453	32 N. LUDLOW ST.	DAYTON	OH	45402	04/12/2019	07/01/2019		07/01/2019
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03458	1331 NORTH FAIRFIELD ROAD	BEAVERCREEK	OH	45432	04/12/2019	07/01/2019		07/01/2019
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03461	3920 LINDEN AVE.	DAYTON	OH	45432	04/12/2019	07/01/2019	07/27/2023	08/02/2023
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03462	4329 WEST 3RD ST	DAYTON	OH	45417	04/12/2019	07/01/2019		07/01/2019
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03467	1300 WILMINGTON AVENUE	DAYTON	OH	45420	04/12/2019	07/01/2019		07/01/2019
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 04477	7541 N MAIN ST.	DAYTON	OH	45415	04/12/2019	07/01/2019	05/25/2022	01/03/2023
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06143	900 N BROAD STREET	FAIRBORN	OH	45324	04/12/2019	07/01/2019	10/05/2022	01/03/2023
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06144	2657 W. ALEX BELL RD	MORAINE	OH	45459	04/12/2019	07/01/2019	09/26/2022	01/03/2023
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 07644	1785 WOODMAN DR.	KETTERING	OH	45420	04/12/2019	07/01/2019	05/25/2022	01/03/2023
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 07767	124 SOUTH MAIN STREET	UNION	OH	45322	04/12/2019	07/01/2019		07/01/2019
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06136	150 SOUTH MAIN STREET	FRANKLIN	OH	45005	01/12/2023	01/12/2023		01/25/2023
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 05364	2375 BEECHWOOD DRIVE	GERMANTOWN	OH	45327	01/26/2023	01/26/2023		01/26/2023
Contract Detail	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06186	2565 EAST MAIN ST.	SPRINGFIELD	OH	45503	01/26/2023	01/26/2023		01/26/2023
Contract Detail	PREMIER PHARMACY SERVICES	410 CLOVERLEAF DR		BALDWIN PARK	CA	91706	07/11/2018	10/01/2018	07/10/2019	07/10/2019
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #11338	10160 INTERNATIONAL BLVD.	WEST CHESTER	OH	45246	01/26/2023	01/26/2023		01/26/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/15/2018	04/01/2018	06/14/2019	07/10/2019
Contract Detail	WAL-MART PHARMACY 10-3783	3465 YORK COMMONS BOULEVARD		DAYTON	OH	45414	01/15/2018	04/01/2018	06/14/2019	07/10/2019
Contract Detail	WAL-MART PHARMACY 10-5409	7725 HOKE ROAD		ENGLEWOOD	OH	45315	01/15/2018	04/01/2018	06/14/2019	07/10/2019
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/15/2018	04/01/2018	06/14/2019	07/10/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01548	5271 SALEM AVENUE	TROTWOOD	OH	45426	10/01/2014	10/03/2014	07/27/2020	08/12/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04520	1260 E CENTRAL	MIAMISBURG	OH	45342	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04521	6495 OLD TROY PIKE	HUBER HEIGHTS	OH	45424	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS #21370	5045 N MAIN ST	DAYTON	OH	45415	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04975	1542 WAYNE AVE.	DAYTON	OH	45410	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04976	2710 SALEM AVE.	DAYTON	OH	45406	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05430	4121 HOOVER AVE	DAYTON	OH	45402	10/01/2014	10/03/2014	04/01/2024	04/08/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05517	2600 S. SMITHVILLE RD.	DAYTON	OH	45420	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06990	183 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07256	2140 E DOROTHY LANE	KETTERING	OH	45420-1114	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07885	5901 SPRINGBORO PIKE	WEST CARROLLTON	OH	45449-3249	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10580	5000 BRANDT PIKE	HUBER HEIGHTS	OH	45424	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	WALGREENS #11846	1213 N. BARRON ST	EATON	OH	45320-1013	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12832	775 W. WENGER RD.	ENGLEWOOD	OH	45322	10/01/2014	10/03/2014		10/03/2014
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12703	537 W. MAIN ST.	XENIA	OH	45385-2811	04/13/2017	07/01/2017		04/13/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS SPECIALTY PHARMACY #16523	1200 BROWN ST STE 160	DAYTON	OH	45409	07/11/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04567	6485 WILMINGTON PIKE	CENTERVILLE	OH	45459	10/12/2022	01/01/2023		01/01/2023
Contract Detail	Walgreens Central Fill #21399	4132Plainfield Rd	Ste 110	Indianapolis	IN	46231-7021	07/13/2023	10/01/2023		10/01/2023
Contract Detail	ZIKS FAMILY PHARMACY, INC #100	1130 W 3RD ST,		DAYTON	OH	45402	01/26/2023	02/06/2023		02/06/2023
Contract Detail	ZIKS FAMILY PHARMACY, INC #102	1120 W 3RD ST		DAYTON	OH	45402	01/17/2023	02/06/2023		02/06/2023

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC26576-00	Active	BPS-H80-033602	Dayton Health Center dba Five Rivers Health Centers	Five Rivers Health Centers Edgemont Campus	721 Miami Chapel Road	Dayton	OH
CHC26576-01	Terminated	BPS-H80-013244	Five Rivers Health Centers	Five Rivers Medical Surgical Health Center	725 South Ludlow	Dayton	OH
CHC26576-02	Active	BPS-H80-033602	Dayton Health Centers dba Five Rivers Health Centers	Five Rivers Health Centers Edgemont Campus	721 Miami Chapel Road	Dayton	OH
CHC26576-03	Active	BPS-H80-015224	Five Rivers Health Centers	Five Rivers Family Health Center	2261 Philadelphia Drive	Dayton	OH
CHC26576-04	Active	BPS-H80-015144	FIVE RIVERS HEALTH CENTERS	Five Rivers Samaritan Homeless Clinic	921 S EDWIN C MOSES BLVD	DAYTON	OH
CHC26576-05	Active	BPS-H80-018967	FIVE RIVERS HEALTH CENTERS	Five Rivers Greene County Health Center	360 Wilson Drive	Xenia	OH
CHC26576-06	Terminated	BPS-H80-021646	Five Rivers Health Centers	Samaritan Homeless Clinic at Key Terrace	3908 Wilmington Pike	Dayton	OH
CHC26576-07	Active	BPS-H80-024959	Five Rivers Health Centers	Five Rivers Health Centers Star Pediatrics	1659 W 2nd St	Xenia	OH
CHC26576-08	Terminated	BPS-H80-028208	Five Rivers Health Centers	Five Rivers Pediatric Center	30 East Apple Street, Ground Floor	Dayton	OH
CHC26576-09	Active	BPS-H80-029758	Five Rivers Health Centers	Five Rivers Health Centers Trotwood Madison Health Center	3594 N Snyder Rd	Dayton	OH
CHC26576-10	Active	BPS-H80-029756	Five Rivers Health Centers	Five Rivers Health Centers Roosevelt Health Center	1923 W 3rd St	Dayton	OH
CHC26576-11	Active	BPS-H80-032468	Five Rivers Health Centers	Five Rivers Health Centers at St. Vincent de Paul	120 W Apple St Ste C	Dayton	OH
CHC26576-12	Terminated	BPS-H80-032520	Five Rivers Health Centers	Five Rivers Gem City Market	324 Salem Ave Ste 100	Dayton	OH

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC26576-00	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/01/2024
CHC26576-00	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/01/2024
CHC26576-00	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/01/2024
CHC26576-00	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/01/2024
CHC26576-00	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	10/01/2024
CHC26576-00	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/01/2024
CHC26576-00	BARR'S PHARMACY	28 W. MAIN ST		XENIA	OH	45385	02/06/2023
CHC26576-04	BARR'S PHARMACY	28 W. MAIN ST		XENIA	OH	45385	01/01/2025
CHC26576-00	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/01/2024
CHC26576-00	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	10/01/2024
CHC26576-00	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	10/01/2024
CHC26576-00	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	10/01/2024
CHC26576-05	FIVE RIVERS HEALTH CENTERS	721 MIAMI CHAPEL RD		DAYTON	OH	45417	07/01/2017	04/25/2017
CHC26576-00	KROGER PHARMACY #014836	3520 WEST SIEBENTHALER AVENUE		DAYTON	OH	45406	07/01/2015	01/07/2016
CHC26576-00	KROGER PHARMACY #765	601 WOODMAN DR		DAYTON	OH	45431	07/01/2015	01/07/2016
CHC26576-00	MIAMI VALLEY PHARMACY		ONE WYOMING STREET	DAYTON	OH	45409	10/03/2014	01/12/2017
CHC26576-02	MIAMI VALLEY PHARMACY		ONE WYOMING STREET	DAYTON	OH	45409	10/03/2014	01/12/2017
CHC26576-03	MIAMI VALLEY PHARMACY		ONE WYOMING STREET	DAYTON	OH	45409	10/03/2014	01/12/2017
CHC26576-01	MIAMI VALLEY PHARMACY		ONE WYOMING STREET	DAYTON	OH	45409	10/03/2014	01/12/2017
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03411	200 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	04/01/2018
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03447	4901 N MAIN ST	DAYTON	OH	45415	04/01/2018
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06141	1001 E. MAIN ST.	TROTWOOD	OH	45426	04/01/2018
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03080	4996 BRANDT PIKE	HUBER HEIGHTS	OH	45424	07/01/2019
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03404	35 S. ALLISON AVE.	XENIA	OH	45385	07/01/2019
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03420	1410 E DOROTHY LN	KETTERING	OH	45429	07/01/2019
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03453	32 N. LUDLOW ST.	DAYTON	OH	45402	07/01/2019
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03458	1331 NORTH FAIRFIELD ROAD	BEAVERCREEK	OH	45432	07/01/2019
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03461	3920 LINDEN AVE.	DAYTON	OH	45432	07/01/2019	07/27/2023
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03462	4329 WEST 3RD ST	DAYTON	OH	45417	07/01/2019
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03467	1300 WILMINGTON AVENUE	DAYTON	OH	45420	07/01/2019
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 04477	7541 N MAIN ST.	DAYTON	OH	45415	07/01/2019	05/25/2022
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06143	900 N BROAD STREET	FAIRBORN	OH	45324	07/01/2019	10/05/2022
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06144	2657 W. ALEX BELL RD	MORAINE	OH	45459	07/01/2019	09/26/2022
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 07644	1785 WOODMAN DR.	KETTERING	OH	45420	07/01/2019	05/25/2022
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 07767	124 SOUTH MAIN STREET	UNION	OH	45322	07/01/2019
CHC26576-01	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 05364	2375 BEECHWOOD DRIVE	GERMANTOWN	OH	45327	10/01/2020	01/01/2023
CHC26576-01	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06136	150 SOUTH MAIN STREET	FRANKLIN	OH	45005	10/01/2020	01/01/2023
CHC26576-01	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06186	2565 EAST MAIN ST.	SPRINGFIELD	OH	45503	10/01/2020	01/01/2023
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06136	150 SOUTH MAIN STREET	FRANKLIN	OH	45005	01/12/2023
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 05364	2375 BEECHWOOD DRIVE	GERMANTOWN	OH	45327	01/26/2023
CHC26576-00	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06186	2565 EAST MAIN ST.	SPRINGFIELD	OH	45503	01/26/2023
CHC26576-00	PREMIER PHARMACY SERVICES	410 CLOVERLEAF DR		BALDWIN PARK	CA	91706	10/01/2018	07/10/2019
CHC26576-01	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #11338	10160 INTERNATIONAL BLVD.	WEST CHESTER	OH	45246	10/01/2020	01/01/2023
CHC26576-00	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #11338	10160 INTERNATIONAL BLVD.	WEST CHESTER	OH	45246	01/26/2023
CHC26576-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2018	06/14/2019
CHC26576-00	WAL-MART PHARMACY 10-3783	3465 YORK COMMONS BOULEVARD		DAYTON	OH	45414	04/01/2018	06/14/2019
CHC26576-00	WAL-MART PHARMACY 10-5409	7725 HOKE ROAD		ENGLEWOOD	OH	45315	04/01/2018	06/14/2019
CHC26576-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2018	06/14/2019
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 01548	5271 SALEM AVENUE	TROTWOOD	OH	45426	10/03/2014	07/27/2020
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 04520	1260 E CENTRAL	MIAMISBURG	OH	45342	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 04521	6495 OLD TROY PIKE	HUBER HEIGHTS	OH	45424	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS #21370	5045 N MAIN ST	DAYTON	OH	45415	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 04975	1542 WAYNE AVE.	DAYTON	OH	45410	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 04976	2710 SALEM AVE.	DAYTON	OH	45406	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 05430	4121 HOOVER AVE	DAYTON	OH	45402	10/03/2014	04/01/2024
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 05517	2600 S. SMITHVILLE RD.	DAYTON	OH	45420	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 06990	183 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 07256	2140 E DOROTHY LANE	KETTERING	OH	45420-1114	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 07885	5901 SPRINGBORO PIKE	WEST CARROLLTON	OH	45449-3249	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS #10580	5000 BRANDT PIKE	HUBER HEIGHTS	OH	45424	10/03/2014
CHC26576-00	WALGREEN CO.	WALGREENS #11846	1213 N. BARRON ST	EATON	OH	45320-1013	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS #12832	775 W. WENGER RD.	ENGLEWOOD	OH	45322	10/03/2014
CHC26576-00	WALGREEN CO.	DBA: WALGREENS #12703	537 W. MAIN ST.	XENIA	OH	45385-2811	07/01/2017
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 01548	5271 SALEM AVENUE	TROTWOOD	OH	45426	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 04975	1542 WAYNE AVE.	DAYTON	OH	45410	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 04520	1260 E CENTRAL	MIAMISBURG	OH	45342	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 04521	6495 OLD TROY PIKE	HUBER HEIGHTS	OH	45424	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS #21370	5045 N MAIN ST	DAYTON	OH	45415	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 04976	2710 SALEM AVE.	DAYTON	OH	45406	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 05430	4121 HOOVER AVE	DAYTON	OH	45402	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 05517	2600 S. SMITHVILLE RD.	DAYTON	OH	45420	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 06990	183 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 07256	2140 E DOROTHY LANE	KETTERING	OH	45420-1114	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS # 07885	5901 SPRINGBORO PIKE	WEST CARROLLTON	OH	45449-3249	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS #10580	5000 BRANDT PIKE	HUBER HEIGHTS	OH	45424	10/03/2014
CHC26576-02	WALGREEN CO.	WALGREENS #11846	1213 N. BARRON ST	EATON	OH	45320-1013	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS #12832	775 W. WENGER RD.	ENGLEWOOD	OH	45322	10/03/2014
CHC26576-02	WALGREEN CO.	DBA: WALGREENS #12703	537 W. MAIN ST.	XENIA	OH	45385-2811	07/01/2017
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 01548	5271 SALEM AVENUE	TROTWOOD	OH	45426	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 04520	1260 E CENTRAL	MIAMISBURG	OH	45342	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 04521	6495 OLD TROY PIKE	HUBER HEIGHTS	OH	45424	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS #21370	5045 N MAIN ST	DAYTON	OH	45415	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 04975	1542 WAYNE AVE.	DAYTON	OH	45410	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 04976	2710 SALEM AVE.	DAYTON	OH	45406	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 05430	4121 HOOVER AVE	DAYTON	OH	45402	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 05517	2600 S. SMITHVILLE RD.	DAYTON	OH	45420	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 06990	183 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 07256	2140 E DOROTHY LANE	KETTERING	OH	45420-1114	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS # 07885	5901 SPRINGBORO PIKE	WEST CARROLLTON	OH	45449-3249	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS #10580	5000 BRANDT PIKE	HUBER HEIGHTS	OH	45424	10/03/2014
CHC26576-03	WALGREEN CO.	WALGREENS #11846	1213 N. BARRON ST	EATON	OH	45320-1013	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS #12832	775 W. WENGER RD.	ENGLEWOOD	OH	45322	10/03/2014
CHC26576-03	WALGREEN CO.	DBA: WALGREENS #12703	537 W. MAIN ST.	XENIA	OH	45385-2811	07/01/2017
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 01548	5271 SALEM AVENUE	TROTWOOD	OH	45426	10/03/2014	01/28/2020
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 04520	1260 E CENTRAL	MIAMISBURG	OH	45342	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 04521	6495 OLD TROY PIKE	HUBER HEIGHTS	OH	45424	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS #21370	5045 N MAIN ST	DAYTON	OH	45415	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 04975	1542 WAYNE AVE.	DAYTON	OH	45410	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 04976	2710 SALEM AVE.	DAYTON	OH	45406	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 05430	4121 HOOVER AVE	DAYTON	OH	45402	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 05517	2600 S. SMITHVILLE RD.	DAYTON	OH	45420	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 06990	183 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 07256	2140 E DOROTHY LANE	KETTERING	OH	45420-1114	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS # 07885	5901 SPRINGBORO PIKE	WEST CARROLLTON	OH	45449-3249	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS #10580	5000 BRANDT PIKE	HUBER HEIGHTS	OH	45424	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	WALGREENS #11846	1213 N. BARRON ST	EATON	OH	45320-1013	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS #12832	775 W. WENGER RD.	ENGLEWOOD	OH	45322	10/03/2014	01/01/2023
CHC26576-01	WALGREEN CO.	DBA: WALGREENS #12703	537 W. MAIN ST.	XENIA	OH	45385-2811	07/01/2017	01/01/2023
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 01548	5271 SALEM AVENUE	TROTWOOD	OH	45426	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 04520	1260 E CENTRAL	MIAMISBURG	OH	45342	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 04521	6495 OLD TROY PIKE	HUBER HEIGHTS	OH	45424	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS #21370	5045 N MAIN ST	DAYTON	OH	45415	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 04975	1542 WAYNE AVE.	DAYTON	OH	45410	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 04976	2710 SALEM AVE.	DAYTON	OH	45406	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 05430	4121 HOOVER AVE	DAYTON	OH	45402	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 05517	2600 S. SMITHVILLE RD.	DAYTON	OH	45420	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 06990	183 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 07256	2140 E DOROTHY LANE	KETTERING	OH	45420-1114	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS # 07885	5901 SPRINGBORO PIKE	WEST CARROLLTON	OH	45449-3249	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS #10580	5000 BRANDT PIKE	HUBER HEIGHTS	OH	45424	01/01/2017
CHC26576-04	WALGREEN CO.	WALGREENS #11846	1213 N. BARRON ST	EATON	OH	45320-1013	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS #12832	775 W. WENGER RD.	ENGLEWOOD	OH	45322	01/01/2017
CHC26576-04	WALGREEN CO.	DBA: WALGREENS #12703	537 W. MAIN ST.	XENIA	OH	45385-2811	07/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS #12832	775 W. WENGER RD.	ENGLEWOOD	OH	45322	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS #12703	537 W. MAIN ST.	XENIA	OH	45385-2811	10/01/2017
CHC26576-05	WALGREEN CO.	WALGREENS #11846	1213 N. BARRON ST	EATON	OH	45320-1013	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS #10580	5000 BRANDT PIKE	HUBER HEIGHTS	OH	45424	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 07885	5901 SPRINGBORO PIKE	WEST CARROLLTON	OH	45449-3249	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 07256	2140 E DOROTHY LANE	KETTERING	OH	45420-1114	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 06990	183 E DAYTON YELLOW SPRINGS RD	FAIRBORN	OH	45324	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 05517	2600 S. SMITHVILLE RD.	DAYTON	OH	45420	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 05430	4121 HOOVER AVE	DAYTON	OH	45402	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 04976	2710 SALEM AVE.	DAYTON	OH	45406	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 04975	1542 WAYNE AVE.	DAYTON	OH	45410	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS #21370	5045 N MAIN ST	DAYTON	OH	45415	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 04521	6495 OLD TROY PIKE	HUBER HEIGHTS	OH	45424	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 04520	1260 E CENTRAL	MIAMISBURG	OH	45342	10/01/2017
CHC26576-05	WALGREEN CO.	DBA: WALGREENS # 01548	5271 SALEM AVENUE	TROTWOOD	OH	45426	10/01/2017
CHC26576-00	WALGREEN CO.	DBA: WALGREENS SPECIALTY PHARMACY #16523	1200 BROWN ST STE 160	DAYTON	OH	45409	10/01/2018
CHC26576-00	WALGREEN CO.	DBA: WALGREENS # 04567	6485 WILMINGTON PIKE	CENTERVILLE	OH	45459	01/01/2023
CHC26576-00	Walgreens Central Fill #21399	4132Plainfield Rd	Ste 110	Indianapolis	IN	46231-7021	10/01/2023
CHC26576-00	ZIKS FAMILY PHARMACY, INC #100	1130 W 3RD ST,		DAYTON	OH	45402	02/06/2023
CHC26576-02	ZIKS FAMILY PHARMACY, INC #100	1130 W 3RD ST,		DAYTON	OH	45402	01/01/2025
CHC26576-00	ZIKS FAMILY PHARMACY, INC #102	1120 W 3RD ST		DAYTON	OH	45402	02/06/2023
CHC26576-05	ZIKS FAMILY PHARMACY, INC #102	1120 W 3RD ST		DAYTON	OH	45402	01/01/2025

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/5/2024 11:06:04 AM	2/12/2025 12:53:08 PM	2/12/2025 12:53 PM
Details	Last Recertification Date	Update	Recertification	1/31/2023 3:10:55 PM	2/5/2024 11:06:04 AM	2/5/2024 11:06 AM
Contacts	Authorizing Official	Update	AO Change Request	Cummins, Diane M. Chief Operating Officer Five Rivers Health Centers 9372815942	McFarlane-El, Gina CEO Five Rivers Health Centers 9372815940	6/12/2023 1:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/8/2023 2:22 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0086072	2/8/2023 2:22 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	2/8/2023 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1497190771	2/8/2023 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	2/8/2023 2:22 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1710530886	2/8/2023 2:22 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	2/8/2023 2:22 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0110907 (OH)		1/31/2023 3:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	1/31/2023 3:10 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0490753	1/31/2023 3:10 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	1/31/2023 3:10 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497190771 (OH)		1/31/2023 3:10 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1962840884 (OH)		1/31/2023 3:10 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1710530886 (OH)		1/31/2023 3:10 PM
Details	Last Recertification Date	Update	Recertification	2/9/2022 10:38:15 AM	1/31/2023 3:10:55 PM	1/31/2023 3:10 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0366508 (OH)		11/17/2022 10:39 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0086072 (OH)		11/17/2022 10:39 AM
Contacts	Primary Contact	Update	Profile Change Request	Tomlin, John Howard Pharmacy Manager Five Rivers Health Centers 9372088850	Tomlin, John Howard Pharmacy Director Five Rivers Health Centers 9372816825	4/20/2022 12:57 PM
Contacts	Authorizing Official	Update	Profile Change Request	Cummins, Diane M. Chief Operating Officer Five Rivers Health Centers 9377346838	Cummins, Diane M. Chief Operating Officer Five Rivers Health Centers 9372815942	4/6/2022 4:18 PM
Addresses	Main Address	Update	Change Request	30 E. Apple Street., Suite L204 Dayton, OH 45409	721 Miami Chapel Road Dayton, OH 45417	3/25/2022 7:17 AM
Addresses	Billing Address	Update	Change Request	Five Rivers Health Centers 2261 Philadelphia Dr. Dayton, OH 45406	Five Rivers Health Centers Edgemont Campus 721 Miami Chapel Road Dayton, OH 45417	3/25/2022 7:17 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1891466280	3/25/2022 7:17 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	3/25/2022 7:17 AM
Details	Entity Subname	Update	Change Request	Five Rivers Dental Center	Five Rivers Health Centers Edgemont Campus	3/25/2022 7:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/10/2022 9:21 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0366508	2/10/2022 9:21 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	2/10/2022 9:21 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1710530886	2/10/2022 9:21 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	2/10/2022 9:21 AM
Details	Last Recertification Date	Update	Recertification	2/3/2021 12:33:37 PM	2/9/2022 10:38:15 AM	2/9/2022 10:38 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1962840884 ( )		2/3/2021 12:33 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497190771 ( )		2/3/2021 12:33 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1497190771	2/3/2021 12:33 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	2/3/2021 12:33 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1962840884	2/3/2021 12:33 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	2/3/2021 12:33 PM
Details	Last Recertification Date	Update	Recertification	1/28/2020 11:11:21 AM	2/3/2021 12:33:37 PM	2/3/2021 12:33 PM
Details	Last Recertification Date	Update	Recertification	1/29/2019 5:10:56 PM	1/28/2020 11:11:21 AM	1/28/2020 11:11 AM
Details	Last Recertification Date	Update	Recertification	2/8/2018 10:04:04 AM	1/29/2019 5:10:56 PM	1/29/2019 5:10 PM
Details	Last Recertification Date	Update	Recertification	1/31/2017 12:00:00 AM	2/8/2018 10:04:04 AM	2/8/2018 10:04 AM
Contacts	Primary Contact	Insert	Change Request		Tomlin, John Howard Pharmacy Manager Five Rivers Health Centers 9372088850	10/6/2017 2:53 PM
Details	Is Authorizing Official EHB Data	Update	Change Request	False		10/6/2017 2:53 PM
Contacts	Authorizing Official	Update		Cummins, Diane M. Chief Operating Officer 9377346838	Cummins, Diane M. Chief Operating Officer Five Rivers Health Centers 9377346838	9/29/2017 3:51 PM
Contacts	Authorizing Official	Insert			Cummins, Diane M. Chief Operating Officer 9377346838	7/12/2017 7:18 PM
Contacts	Signed By	Insert			Bridge, Dave CFO 9377346844	7/6/2017 2:35 PM
Addresses	Main Address	Insert			30 E. Apple Street., Suite L204 Dayton, OH 45409	4/11/2017 11:39 AM
Addresses	Billing Address	Insert			Five Rivers Health Centers 2261 Philadelphia Dr. Dayton, OH 45406	4/11/2017 11:39 AM
Details	Last Recertification Date	Update		2/25/2016 12:00:00 AM	1/31/2017 12:00:00 AM	1/31/2017 9:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/29/2016 8:48 AM
Medicaid Billing	Medicaid: Number	Insert			0086072	2/29/2016 8:48 AM
Medicaid Billing	Medicaid: State	Insert			OH	2/29/2016 8:48 AM
Medicaid Billing	NPI: Number	Insert			1497190771	2/29/2016 8:48 AM
Details	Last Recertification Date	Update		3/4/2015 12:00:00 AM	2/25/2016 12:00:00 AM	2/25/2016 1:27 PM
Details	Last Recertification Date	Update			3/4/2015 12:00:00 AM	3/4/2015 11:28 AM
Medicaid Billing	Medicaid: Number	Update		0085442	0110907	11/12/2014 10:43 AM
Medicaid Billing	NPI: Number	Update		1750729661	1962840884	11/12/2014 10:43 AM
Details	Is Authorizing Official EHB Data	Update			False	11/12/2014 10:43 AM
Details	340B ID	Update		ONLINE_REG	CHC26576-00	4/30/2014 4:42 PM
Dates	Participating Approval Date	Update			4/30/2014 12:00:00 AM	4/30/2014 4:42 PM
Details	State	Update		Pending	Active	4/30/2014 4:42 PM
Dates	Start Date	Update			7/1/2014 12:00:00 AM	4/30/2014 4:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/14/2014 12:44 PM
Medicaid Billing	Medicaid: Number	Insert			0085442	4/14/2014 12:44 PM
Medicaid Billing	Medicaid: State	Insert			OH	4/14/2014 12:44 PM
Medicaid Billing	NPI: Number	Insert			1750729661	4/14/2014 12:44 PM
Details	Last Recertification Date	Insert				4/14/2014 12:44 PM
Details	Grant Number	Insert			H80CS26576	4/14/2014 12:44 PM
Details	340B ID	Insert			ONLINE_REG	4/14/2014 12:44 PM
Details	Is Authorizing Official EHB Data	Insert				4/14/2014 12:44 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/14/2014 12:44 PM
Details	Medicare Provider Number	Insert				4/14/2014 12:44 PM
Details	Entity Name	Insert			Dayton Health Center dba Five Rivers Health Centers	4/14/2014 12:44 PM
Details	Program Code	Insert			CH	4/14/2014 12:44 PM
Details	Entity Subname	Insert			Five Rivers Dental Center	4/14/2014 12:44 PM
Dates	Participating Approval Date	Insert				4/14/2014 12:44 PM
Details	State	Insert			Pending	4/14/2014 12:44 PM
Dates	Registration Date	Insert			4/14/2014 12:00:00 AM	4/14/2014 12:44 PM
Dates	Signed By Date	Insert			4/14/2014 12:00:00 AM	4/14/2014 12:44 PM
Dates	Start Date	Insert				4/14/2014 12:44 PM
Terminations	Termination Comments	Insert				4/14/2014 12:44 PM
Terminations	Termination Date	Insert				4/14/2014 12:44 PM
Terminations	Termination Effective Date	Insert				4/14/2014 12:44 PM
Terminations	Termination Reason	Insert				4/14/2014 12:44 PM

340B Drug Pricing Program Database