Covered Entity Details

DSH510046A PRINCETON COMMUNITY HOSPITAL (Active) - information as of 6/6/2025 4:27:16 AM

Main Details

Name

PRINCETON COMMUNITY HOSPITAL

Subdivision Name

BEHAVIORAL HEALTH PAVILION-OUTPATIENT TREATMENT

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH510046A

Medicare Provider Number

510046

Outpatient Facility Provider Number

510046

Additional Details

Current Program Status

Active

Registration Date

7/14/2014

Participating Start Date

10/1/2014

Participating Approval Date

9/4/2014

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Princeton Community Hospital Association, Inc.
Diane Lynn Spencer, VP of Finance/CFO
(304) 487-7505

Primary Contact

Princeton Community Hospital
Daniel Paul Morrison, Director of Pharmacy
(304) 487-7564

Addresses

Street Address

1333 SOUTHVIEW DRIVE
BLUEFIELD, WV 24701

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
WV		1558313213,1619053329,1972610863,1972810125,1063729218
VA		1558313213,1619053329,1972610863,1972810125,1063729218
OH		1558313213,1619053329,1972610863,1972810125,1063729218
PA		1558313213,1619053329,1972610863,1972810125,1063729218
KY		1558313213,1619053329,1972610863,1972810125,1063729218

Shipping Addresses

Shipping Address 1

West Virginia United Health System Inc DBA Enterprise Pharmacy Solutions
781 Chestnut Ridge Rd
Suite 600
Morgantown, WV 26505-0015

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
DSH510046A	Child	DSH	PRINCETON COMMUNITY HOSPITAL	BEHAVIORAL HEALTH PAVILION-OUTPATIENT TREATMENT	1333 SOUTHVIEW DRIVE	BLUEFIELD	WV	Active
DSH510046B	Child	DSH	PRINCETON COMMUNITY HOSPITAL	PRINCETON COMMUNITY HOSPITAL - Rural Health Clinic 2	401 E VERMILLION ST	ATHENS	WV	Active
DSH510046C	Child	DSH	PRINCETON COMMUNITY HOSPITAL	PCH BLUEFIELD ED - Emergency Department	500 CHERRY ST	BLUEFIELD	WV	Active
DSH510046D	Child	DSH	PRINCETON COMMUNITY HOSPITAL	WVU Cancer Institute PCH Cancer Medicine - Hematology/Oncology	122 Twelfth Street	Princeton	WV	Terminated
DSH510046E	Child	DSH	PRINCETON COMMUNITY HOSPITAL	PRINCETON COMMUNITY HOSPITAL ASSOC. - Bluefield Internal Medicine	510 CHERRY ST	BLUEFIELD	WV	Active
DSH510046F	Child	DSH	PRINCETON COMMUNITY HOSPITAL	Bluefield Family Medicine - Bluefield Family Medicine	106 Huffard Drive	Bluefield	VA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Group Change Request		West Virginia United Health System Inc DBA Enterprise Pharmacy Solutions 781 Chestnut Ridge Rd Suite 600 Morgantown, WV 26505-0015	10/22/2024 9:11 AM
Details	Last Recertification Date	Update	Recertification	8/25/2023 10:05:59 AM	8/14/2024 3:09:23 PM	8/14/2024 3:09 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	010065000 (MD)		6/7/2024 2:02 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1558313213 (MD)		6/7/2024 2:02 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1558313213 (NC)		6/7/2024 2:02 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1558313213 (SC)		6/7/2024 2:02 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1558313213 (TN)		6/7/2024 2:02 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0001110000 (WV)		6/5/2024 11:11 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	005100461 (VA)		6/5/2024 11:11 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0233590 (OH)		6/5/2024 11:11 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	000820535-0001 (PA)		6/5/2024 11:11 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	12010B (SC)		6/5/2024 11:11 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0510046 (TN)		6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619053329	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972610863	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972810125	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1063729218	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619053329	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972610863	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972810125	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1063729218	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OH	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619053329	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972610863	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972810125	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1063729218	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619053329	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972610863	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972810125	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1063729218	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		VA	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1558313213	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619053329	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972610863	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972810125	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/5/2024 11:11 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1063729218	6/5/2024 11:11 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		KY	6/5/2024 11:11 AM
Contacts	Primary Contact	Update	Group Change Request	Morrison, Daniel Paul Director of Pharmacy Princeton Community Hospital 3044877564	Morrison, Daniel Paul Director of Pharmacy Princeton Community Hospital 3044877564	9/12/2023 1:58 PM
Contacts	Authorizing Official	Update	AO Change Request	Spencer, Diane Lynn VP of Finance/CFO Princeton Community Hospital Association, Inc 3044877505	Spencer, Diane Lynn VP of Finance/CFO Princeton Community Hospital Association, Inc. 3044877505	9/12/2023 10:25 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 1:49:25 PM	8/25/2023 10:05:59 AM	8/25/2023 10:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0001110000	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		005100461	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010065000	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0233590	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000820535-0001	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		12010B	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0510046	8/29/2022 10:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	8/29/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558313213	8/29/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	8/29/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558313213	8/29/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	8/29/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558313213	8/29/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		MD	8/29/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558313213	8/29/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	8/29/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558313213	8/29/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	8/29/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558313213	8/29/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	8/29/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558313213	8/29/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	8/29/2022 10:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558313213	8/29/2022 10:19 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	8/29/2022 10:19 AM
Details	Last Recertification Date	Update	Recertification	8/25/2021 2:02:50 PM	8/24/2022 1:49:25 PM	8/24/2022 1:49 PM
Contacts	Authorizing Official	Update	AO Change Request	SINICROPE, FRANK CFO Princeton Community Hospital 3044877263	Spencer, Diane Lynn VP of Finance/CFO Princeton Community Hospital Association, Inc 3044877505	8/9/2022 12:59 PM
Details	Last Recertification Date	Update	Recertification	8/26/2020 9:47:08 AM	8/25/2021 2:02:50 PM	8/25/2021 2:02 PM
Details	Last Recertification Date	Update	Recertification	8/23/2019 9:05:08 AM	8/26/2020 9:47:08 AM	8/26/2020 9:47 AM
Details	Last Recertification Date	Update	Recertification	8/20/2018 10:07:09 AM	8/23/2019 9:05:08 AM	8/23/2019 9:05 AM
Contacts	Primary Contact	Update	Recertification	DRADY, SUSAN DIRECTOR OF PHARMACY Princeton Community Hospital 3044877564	Morrison, Daniel Paul Director of Pharmacy Princeton Community Hospital 3044877564	8/20/2018 10:07 AM
Details	Last Recertification Date	Update	Recertification	11/7/2017 1:41:17 PM	8/20/2018 10:07:09 AM	8/20/2018 10:07 AM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/7/2017 1:41:17 PM	11/7/2017 1:41 PM
Contacts	Primary Contact	Update	Recertification	DRADY, SUSAN DIRECTOR OF PHARMACY 3044877564	DRADY, SUSAN DIRECTOR OF PHARMACY Princeton Community Hospital 3044877564	11/7/2017 1:40 PM
Contacts	Authorizing Official	Update		SINICROPE, FRANK CFO 3044877263	SINICROPE, FRANK CFO Princeton Community Hospital 3044877263	11/7/2017 1:22 PM
Contacts	Signed By	Update		SINICROPE, FRANK CFO 3044877263	SINICROPE, FRANK CFO Princeton Community Hospital 3044877263	11/7/2017 1:22 PM
Contacts	Authorizing Official	Insert			SINICROPE, FRANK CFO 3044877263	11/21/2016 2:35 PM
Contacts	Signed By	Insert			SINICROPE, FRANK CFO 3044877263	11/21/2016 2:35 PM
Addresses	Main Address	Insert			1333 SOUTHVIEW DRIVE BLUEFIELD, WV 24701	8/10/2016 4:25 PM
Contacts	Primary Contact	Insert			DRADY, SUSAN DIRECTOR OF PHARMACY 3044877564	8/10/2016 4:25 PM
Details	Last Recertification Date	Update		8/18/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 4:25 PM
Details	Entity Subname	Update		BEHAVIORAL HEALTH PAVILION	BEHAVIORAL HEALTH PAVILION-OUTPATIENT TREATMENT	6/30/2016 2:20 PM
Details	Last Recertification Date	Update			8/18/2015 12:00:00 AM	8/18/2015 10:00 AM
Dates	Participating Approval Date	Update			9/4/2014 12:00:00 AM	9/4/2014 11:49 AM
Details	State	Update		Pending	Active	9/4/2014 11:49 AM
Dates	Start Date	Update			10/1/2014 12:00:00 AM	9/4/2014 11:49 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_45578	DSH510046A	9/1/2014 6:45 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_45578	7/14/2014 12:26 PM
Details	Last Recertification Date	Insert				7/14/2014 12:26 PM
Details	Grant Number	Insert				7/14/2014 12:26 PM
Details	340B ID	Insert				7/14/2014 12:26 PM
Details	Is Authorizing Official EHB Data	Insert				7/14/2014 12:26 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/14/2014 12:26 PM
Details	Medicare Provider Number	Insert			510046	7/14/2014 12:26 PM
Details	Entity Name	Insert			PRINCETON COMMUNITY HOSPITAL	7/14/2014 12:26 PM
Details	Program Code	Insert			DSH	7/14/2014 12:26 PM
Details	Entity Subname	Insert			BEHAVIORAL HEALTH PAVILION	7/14/2014 12:26 PM
Dates	Participating Approval Date	Insert				7/14/2014 12:26 PM
Details	State	Insert			Pending	7/14/2014 12:26 PM
Dates	Registration Date	Insert			7/14/2014 12:00:00 AM	7/14/2014 12:26 PM
Dates	Signed By Date	Insert			7/14/2014 12:00:00 AM	7/14/2014 12:26 PM
Dates	Start Date	Insert				7/14/2014 12:26 PM
Terminations	Termination Comments	Insert				7/14/2014 12:26 PM
Terminations	Termination Date	Insert				7/14/2014 12:26 PM
Terminations	Termination Effective Date	Insert				7/14/2014 12:26 PM
Terminations	Termination Reason	Insert				7/14/2014 12:26 PM