Covered Entity Details

DSH440050R TAKOMA REGIONAL HOSPITAL (Terminated) - information as of 5/8/2025 10:25:24 PM

Main Details

Name

TAKOMA REGIONAL HOSPITAL

Subdivision Name

TAKOMA MEDICAL ASSOCIATES / Cardiovascular Associates

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH440050R

Medicare Provider Number

440050

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

1/15/2015

Participating Start Date

4/1/2015

Participating Approval Date

3/4/2015

Last Recertification Date

11/9/2017

Termination Date
Termination Reason

4/1/2018
Business decision by the Covered Entity

Contacts

Authorizing Official

Ballad Health
Shane Hilton, EVP, Chief Financial Officer
(423) 302-3467

Primary Contact

Wellmont Health System
ALLAN SHARP, PHARMACIST
(423) 578-8541

Addresses

Street Address

1021 Coolidge Street
Suite 5
Greeneville, TN 37743-7202

Billing Address

WELLMONT HEALTH SYSTEM
PO BOX 659
KINGSPORT, TN 37662

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
		1699819003

Shipping Addresses

Shipping Address 1

Takoma Regional Hospital
401 Takoma Ave
Greeneville, TN 37743

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
DSH440050B	Child	DSH	TAKOMA REGIONAL HOSPITAL	GREENEVILLE URGENT CARE AND INDUSTRICARE	1021 COOLIDGE STREET	GREENEVILLE	TN	Terminated
DSH440050C	Child	DSH	Greeneville Community Hospital	BHMA Family Medicine	438 East Vann Rd	Greeneville	TN	Terminated
DSH440050D	Child	DSH	Greeneville Community Hospital	Takoma Medical Associates-General and Vascular Surgery	438 E. Vann Rd	Greeneville	TN	Terminated
DSH440050E	Child	DSH	Greeneville Community Hospital	BHMA Internal Medicine	438 E. Vann Rd	Greeneville	TN	Terminated
DSH440050F	Child	DSH	Greeneville Community Hospital	BHMA Gastroenterology	1406 Tusculum Blvd	Greeneville	TN	Terminated
DSH440050G	Child	DSH	TAKOMA REGIONAL HOSPITAL	Takoma Medical Associates-Sports Medicine	438 E. Vann Rd	Greeneville	TN	Terminated
DSH440050H	Child	DSH	TAKOMA REGIONAL HOSPITAL	TAKOMA OUTPATIENT BEHAVIORAL HEALTH	303 Takoma Ave.	Greeneville	TN	Terminated
DSH440050J	Child	DSH	Greeneville Community Hospital	BHMA Family Medicine and Internal Medicine	438 E Vann Rd.	Greeneville	TN	Terminated
DSH440050L	Child	DSH	TAKOMA REGIONAL HOSPITAL	Takoma Regional Hospital Sleep Center	1024 Coolidge Street	Greeneville	TN	Terminated
DSH440050M	Child	DSH	TAKOMA REGIONAL HOSPITAL	Takoma Regional Hospital Center for Rehabilitation	108 West Summer Street	Greeneville	TN	Terminated
DSH440050N	Child	DSH	TAKOMA REGIONAL HOSPITAL	Diagnostic Center for Women's Health at Takoma Regional Hospital	438 E. Vann Rd	Greeneville	TN	Terminated
DSH440050P	Child	DSH	TAKOMA REGIONAL HOSPITAL	Takoma Medical Associates - Podiatry	438 E VANN RD	GREENEVILLE	TN	Terminated
DSH440050Q	Child	DSH	TAKOMA REGIONAL HOSPITAL	Takoma Medical Associates - Physical Medicine and Rehab	438 E. Vann Rd.	Greeneville	TN	Terminated
DSH440050R	Child	DSH	TAKOMA REGIONAL HOSPITAL	TAKOMA MEDICAL ASSOCIATES / Cardiovascular Associates	1021 Coolidge Street	Greeneville	TN	Terminated
DSH440050S	Child	DSH	TAKOMA REGIONAL HOSPITAL	TAKOMA MEDICAL ASSOCIATES / Orthopedics	438 E VANN RD	GREENEVILLE	TN	Terminated
DSH440050T	Child	DSH	Greeneville Community Hospital	TAKOMA MEDICAL ASSOCIATES / Neurology	438 E VANN RD	GREENEVILLE	TN	Terminated
DSH440050U	Child	DSH	Greeneville Community Hospital	BHMA Family Medicine	1404 Tusculum Blvd	GREENEVILLE	TN	Terminated
DSH440050V	Child	DSH	Greeneville Community Hospital	BHMA OBGN and Womens Health	1424 Tusculum Blvd.	Greeneville	TN	Terminated
DSH440050W	Child	DSH	TAKOMA REGIONAL HOSPITAL	INFUSION CENTER B - INFUSION	401 TAKOMA AVENUE	GREENEVILLE	TN	Terminated
DSH440050X	Child	DSH	TAKOMA REGIONAL HOSPITAL	INFUSION CENTER A - INFUSION	401 TAKOMA AVENUE	GREENEVILLE	TN	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Hilton, Shane Sr VP, Market Financial Operations Ballad Health 4233023467	Hilton, Shane EVP, Chief Financial Officer Ballad Health 4233023467	4/25/2024 2:38 PM
Contacts	Authorizing Official	Update	Change Request	Dougan, Todd j. CFO Wellmont Health System 4232308512	Hilton, Shane Sr VP, Market Financial Operations Ballad Health 4233023467	4/20/2018 7:12 AM
Details	State	Update		To Be Terminated	Terminated	4/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/28/2018 12:00:00 AM	3/1/2018 10:46 AM
Details	State	Update	Termination Request	Active	To Be Terminated	3/1/2018 10:46 AM
Terminations	Termination Date	Update	Termination Request		4/1/2018 12:00:00 AM	3/1/2018 10:46 AM
Terminations	Termination Effective Date	Update	Termination Request		3/1/2018 12:00:00 AM	3/1/2018 10:46 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	3/1/2018 10:46 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	440050 (TN)		2/21/2018 2:03 PM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	11/9/2017 10:39:50 AM	11/9/2017 10:39 AM
Contacts	Authorizing Official	Update		Dougan, Todd j. CFO 4232308512	Dougan, Todd j. CFO Wellmont Health System 4232308512	10/13/2017 10:39 AM
Contacts	Primary Contact	Update		SHARP, ALLAN PHARMACIST 4235788541	SHARP, ALLAN PHARMACIST Wellmont Health System 4235788541	9/20/2017 2:10 PM
Contacts	Signed By	Update	Change Request	MILLER, STEVEN VP/CFO 6065981035	MILLER, STEVEN VP FINANCE/CFO MANCHESTER MEMORIAL HOSPITAL 6065981035	9/20/2017 1:12 PM
Contacts	Signed By	Insert			MILLER, STEVEN VP/CFO 6065981035	8/10/2017 5:14 PM
Contacts	Authorizing Official	Update		Blair, Michael Interim CFO 4236362350	Dougan, Todd j. CFO 4232308512	7/18/2017 7:53 AM
Contacts	Primary Contact	Insert			SHARP, ALLAN PHARMACIST 4235788541	5/11/2017 7:23 AM
Addresses	Main Address	Insert			1021 Coolidge Street Suite 5 Greeneville, TN 37743-7202	1/12/2017 3:07 PM
Addresses	Billing Address	Insert			WELLMONT HEALTH SYSTEM PO BOX 659 KINGSPORT, TN 37662	1/12/2017 3:07 PM
Addresses	Shipping Address	Insert			Takoma Regional Hospital 401 Takoma Ave Greeneville, TN 37743	1/12/2017 3:07 PM
Contacts	Authorizing Official	Insert			Blair, Michael Interim CFO 4236362350	1/6/2017 12:45 PM
Details	Last Recertification Date	Update		8/11/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 1:59 PM
Details	Last Recertification Date	Update			8/11/2015 12:00:00 AM	8/11/2015 11:38 AM
Dates	Participating Approval Date	Update			3/4/2015 12:00:00 AM	3/4/2015 3:46 PM
Details	State	Update		Pending	Active	3/4/2015 3:46 PM
Dates	Start Date	Update			4/1/2015 12:00:00 AM	3/4/2015 3:46 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_50095	DSH440050R	1/22/2015 9:54 AM
Details	Entity Subname	Update		TAKOMA MEDICAL ASSOCIATES / Takoma Medical Associates - Cardiovascular Associates	TAKOMA MEDICAL ASSOCIATES / Cardiovascular Associates	1/22/2015 9:54 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_50095	1/15/2015 9:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/15/2015 9:58 PM
Medicaid Billing	Medicaid: Number	Insert			440050	1/15/2015 9:58 PM
Medicaid Billing	Medicaid: State	Insert			TN	1/15/2015 9:58 PM
Medicaid Billing	NPI: Number	Insert			1699819003	1/15/2015 9:58 PM
Details	Last Recertification Date	Insert				1/15/2015 9:58 PM
Details	Grant Number	Insert				1/15/2015 9:58 PM
Details	340B ID	Insert				1/15/2015 9:58 PM
Details	Is Authorizing Official EHB Data	Insert				1/15/2015 9:58 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/15/2015 9:58 PM
Details	Medicare Provider Number	Insert			440050	1/15/2015 9:58 PM
Details	Entity Name	Insert			TAKOMA REGIONAL HOSPITAL	1/15/2015 9:58 PM
Details	Program Code	Insert			DSH	1/15/2015 9:58 PM
Details	Entity Subname	Insert			TAKOMA MEDICAL ASSOCIATES / Takoma Medical Associates - Cardiovascular Associates	1/15/2015 9:58 PM
Dates	Participating Approval Date	Insert				1/15/2015 9:58 PM
Details	State	Insert			Pending	1/15/2015 9:58 PM
Dates	Registration Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 9:58 PM
Dates	Signed By Date	Insert			1/15/2015 12:00:00 AM	1/15/2015 9:58 PM
Dates	Start Date	Insert				1/15/2015 9:58 PM
Terminations	Termination Comments	Insert				1/15/2015 9:58 PM
Terminations	Termination Date	Insert				1/15/2015 9:58 PM
Terminations	Termination Effective Date	Insert				1/15/2015 9:58 PM
Terminations	Termination Reason	Insert				1/15/2015 9:58 PM