Covered Entity Details

DSH340151A Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital (Active) - information as of 5/25/2025 1:22:22 AM

Main Details

Name

Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital

Subdivision Name

MRI

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH340151A

Medicare Provider Number

340151

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2015

Participating Start Date

4/1/2015

Participating Approval Date

2/10/2015

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

ECU Health North Hospital
Ryan Todd Hickey, President
(252) 535-8159

Primary Contact

ECU Health North Hospital
Amy Bennett, Pharmacy Manager
(252) 535-8274

Addresses

Street Address

210 Smith Church Road
Roanoke Rapids, NC 27870

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
FL	1346273943	1346273943
MD	1346273943	1346273943
NY	1346273943	1346273943
SC	1346273943	1346273943
VA	1346273943	1346273943
NJ	1346273943	1346273943
DC	1346273943	1346273943
PA	1346273943	1346273943
KY	1346273943	1346273943
MA	1346273943	1346273943
OH	1346273943	1346273943
CA	1346273943	1346273943
TX	1346273943	1346273943
AZ	1346273943	1346273943
ID	1346273943	1346273943
TN	1346273943	1346273943
NM	1346273943	1346273943
UT	1346273943	1346273943
MN	1346273943	1346273943
MO	1346273943	1346273943
NC	1346273943	1346273943
GA	1346273943	1346273943
LA	1346273943	1346273943
IN	1346273943	1346273943

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
DSH340151A	Child	DSH	Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital	MRI	210 Smith Church Road	Roanoke Rapids	NC	Active
DSH340151B	Child	DSH	Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital	The Wound Care Center	244A Smith Church Road	Roanoke Rapids	NC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Campbell, Dennis President (interim) ECU Health- North Hospital 2525358115	Hickey, Ryan Todd President ECU Health North Hospital 2525358159	2/25/2025 6:48 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/13/2024 8:59 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	12/13/2024 8:59 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	12/13/2024 8:59 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	12/13/2024 8:59 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	12/13/2024 8:59 AM
Contacts	Primary Contact	Update	Profile Change Request	Bennett, Amy Pharmacy Director ECU Health North Hospital 2525358274	Bennett, Amy Pharmacy Manager ECU Health North Hospital 2525358274	10/28/2024 9:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/22/2024 7:32 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/22/2024 7:32 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	8/22/2024 7:32 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/22/2024 7:32 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/22/2024 7:32 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	8/22/2024 7:32 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/22/2024 7:32 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/22/2024 7:32 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/22/2024 7:32 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/22/2024 7:32 AM
Details	Last Recertification Date	Update	Recertification	8/31/2023 6:57:44 AM	8/22/2024 7:32:17 AM	8/22/2024 7:32 AM
Contacts	Authorizing Official	Update	AO Change Request	Harrell, Jason President ECU Health North Hospital 2525358115	Campbell, Dennis President (interim) ECU Health- North Hospital 2525358115	8/13/2024 12:13 PM
Details	Last Recertification Date	Update	Recertification	9/1/2022 7:29:20 AM	8/31/2023 6:57:44 AM	8/31/2023 6:57 AM
Contacts	Authorizing Official	Update	Change Request	Harrell, Jason Barnes President Halifax Regional Medical Center 2525358159	Harrell, Jason President ECU Health North Hospital 2525358115	6/1/2023 7:42 AM
Contacts	Primary Contact	Update	Group Change Request	Bennett, Amy Pharmacy Director Halifax Regional Medical Center 2525358274	Bennett, Amy Pharmacy Director ECU Health North Hospital 2525358274	5/30/2023 7:51 AM
Details	Last Recertification Date	Update	Recertification	8/31/2021 11:30:14 AM	9/1/2022 7:29:20 AM	9/1/2022 7:29 AM
Details	Entity Name	Update	Change Request	HALIFAX REGIONAL MEDICAL CENTER, INC., D/B/A VIDANT NORTH HOSPITAL	Halifax Regional Medical Center, Inc. d/b/a ECU Health North Hospital	6/23/2022 7:04 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (MI)		8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (GA)		8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (CT)		8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (IL)		8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (IN)		8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		UT	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (MI)		8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (GA)		8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (CT)		8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (IL)		8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 (IN)		8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	8/31/2021 11:30 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/31/2021 11:30 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	8/31/2021 11:30 AM
Details	Last Recertification Date	Update	Recertification	8/17/2020 9:26:27 AM	8/31/2021 11:30:14 AM	8/31/2021 11:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	9/11/2020 8:54 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	NPI: State	Insert	Change Request		CT	9/11/2020 8:54 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	9/11/2020 8:54 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	9/11/2020 8:54 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	9/11/2020 8:54 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	NPI: State	Insert	Change Request		MA	9/11/2020 8:54 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	9/11/2020 8:54 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	9/11/2020 8:54 AM
Contacts	Authorizing Official	Update	Change Request	Mahone, William President Halifax Regional Medical Center 2525358111	Harrell, Jason Barnes President Halifax Regional Medical Center 2525358159	9/4/2020 9:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1346273943	8/17/2020 9:26 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 9:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1346273943 ( )		8/17/2020 9:26 AM
Details	Last Recertification Date	Update	Recertification	9/10/2019 10:12:53 AM	8/17/2020 9:26:27 AM	8/17/2020 9:26 AM
Details	Entity Name	Update	Change Request	HALIFAX REGIONAL MEDICAL CENTER	HALIFAX REGIONAL MEDICAL CENTER, INC., D/B/A VIDANT NORTH HOSPITAL	2/28/2020 7:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DC	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/11/2020 8:06 AM
Details	Entity Subname	Update	Change Request	Halifax Regional Medical Center MRI	MRI	2/11/2020 8:06 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (CA)		9/10/2019 10:12 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1346273943 (WV)		9/10/2019 10:12 AM
Details	Last Recertification Date	Update	Recertification	8/23/2018 7:46:44 AM	9/10/2019 10:12:53 AM	9/10/2019 10:12 AM
Contacts	Authorizing Official	Update	Change Request	Mahone, William CEO Halifax Regional Medical Center 2525358011	Mahone, William President Halifax Regional Medical Center 2525358111	6/11/2019 9:22 AM
Contacts	Primary Contact	Update	Change Request	Bennett, Amy Tromans Director of Pharmacy Halifax Regional Medical Center 2525358274	Bennett, Amy Pharmacy Director Halifax Regional Medical Center 2525358274	6/7/2019 10:26 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	092444000	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000280607X (GA)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	424745100	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110027713B (MA)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	4175905 (NJ)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	00352685	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0007897300001 (PA)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	272280 (SC)		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	10025A	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	009810331	1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346273943	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	3400151	1346273943	6/7/2019 10:10 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1558407585 ( )		6/7/2019 10:10 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110027713B (MA)		11/12/2018 2:59 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	00352685 (NY)		11/12/2018 2:59 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		092444000	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000280607X	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		424745100	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110027713B	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110027713B	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4175905	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00352685	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00352685	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0007897300001	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		272280	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10025A	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		009810331	11/12/2018 2:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	11/12/2018 2:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346273943	11/12/2018 2:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1558407585	11/12/2018 2:51 PM
Details	Last Recertification Date	Update	Recertification	11/3/2017 1:09:24 PM	8/23/2018 7:46:44 AM	8/23/2018 7:46 AM
Contacts	Primary Contact	Update	Profile Change Request	Bennett, Amy Tromans Director of Pharmacy Halifax Regional Medical Center 2525358761	Bennett, Amy Tromans Director of Pharmacy Halifax Regional Medical Center 2525358274	8/21/2018 3:18 PM
Contacts	Primary Contact	Update	Change Request	Lehman, David Christian Director of Pharmacy Services Halifax Regional Medical Center 2525358274	Bennett, Amy Tromans Director of Pharmacy Halifax Regional Medical Center 2525358761	6/29/2018 10:17 AM
Contacts	Primary Contact	Insert	Recertification		Lehman, David Christian Director of Pharmacy Services Halifax Regional Medical Center 2525358274	11/3/2017 1:09 PM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	11/3/2017 1:09:24 PM	11/3/2017 1:09 PM
Contacts	Authorizing Official	Insert			Mahone, William CEO Halifax Regional Medical Center 2525358011	8/29/2016 12:01 PM
Contacts	Signed By	Insert			Mahone, William CEO Halifax Regional Medical Center 2525358011	8/29/2016 12:01 PM
Addresses	Main Address	Insert			210 Smith Church Road Roanoke Rapids, NC 27870	8/29/2016 12:01 PM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 12:01 PM
Details	Last Recertification Date	Update			8/5/2015 12:00:00 AM	8/5/2015 11:05 AM
Dates	Participating Approval Date	Update			2/10/2015 12:00:00 AM	2/10/2015 6:38 PM
Details	State	Update		Pending	Active	2/10/2015 6:38 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	2/10/2015 6:38 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_49866	DSH340151A	1/29/2015 2:39 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_49866	1/15/2015 3:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2015 3:21 PM
Medicaid Billing	Medicaid: Number	Insert			3400151	1/15/2015 3:21 PM
Medicaid Billing	Medicaid: State	Insert			NC	1/15/2015 3:21 PM
Details	Last Recertification Date	Insert				1/15/2015 3:21 PM
Details	Grant Number	Insert				1/15/2015 3:21 PM
Details	340B ID	Insert				1/15/2015 3:21 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2015 3:21 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2015 3:21 PM
Details	Medicare Provider Number	Insert			340151	1/15/2015 3:21 PM
Details	Entity Name	Insert			HALIFAX REGIONAL MEDICAL CENTER	1/15/2015 3:21 PM
Details	Program Code	Insert			DSH	1/15/2015 3:21 PM
Details	Entity Subname	Insert			Halifax Regional Medical Center MRI	1/15/2015 3:21 PM
Dates	Participating Approval Date	Insert				1/15/2015 3:21 PM
Details	State	Insert			Pending	1/15/2015 3:21 PM
Dates	Registration Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 3:21 PM
Dates	Signed By Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 3:21 PM
Dates	Start Date	Insert				1/15/2015 3:21 PM
Terminations	Termination Comments	Insert				1/15/2015 3:21 PM
Terminations	Termination Date	Insert				1/15/2015 3:21 PM
Terminations	Termination Effective Date	Insert				1/15/2015 3:21 PM
Terminations	Termination Reason	Insert				1/15/2015 3:21 PM