| Details | Last Recertification Date | Update | Recertification | 9/6/2023 11:04:37 AM | 8/23/2024 9:27:42 AM | 8/23/2024 9:27 AM |
| Contacts | Primary Contact | Update | Group Change Request | Lastrapes, Marcia P
340B Program Manager
Emory Healthcare
8633990008 | Kchao, Sydney
Corporate Director of Pharmacy, Business Operations and Finance
Emory Healthcare
4046862147 | 5/21/2024 9:21 AM |
| Details | Last Recertification Date | Update | Recertification | 8/30/2022 9:40:26 AM | 9/6/2023 11:04:37 AM | 9/6/2023 11:04 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2021 9:26:24 AM | 8/30/2022 9:40:26 AM | 8/30/2022 9:40 AM |
| Contacts | Authorizing Official | Update | Change Request | Daunt-Samford, Liz
CFO
DeKalb Medical
4045015025 | Urbistondo, Lisa
Vice President & CFO
Emory Decatur, Emory Hillandale
4045015025 | 7/12/2022 9:47 AM |
| Details | Last Recertification Date | Update | Recertification | 9/16/2020 10:51:47 AM | 8/16/2021 9:26:24 AM | 8/16/2021 9:26 AM |
| Contacts | Primary Contact | Update | Change Request | Mindel, Kristina
Pharmacy Manager
Emory Decatur Hospital
4045015044 | Lastrapes, Marcia P
340B Program Manager
Emory Healthcare
8633990008 | 7/12/2021 8:38 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | GA | 9/16/2020 10:51 AM |
| Contacts | Primary Contact | Update | Recertification | Mindel, Kristina
Pharmacy Manager
DeKalb Medical
4045015044 | Mindel, Kristina
Pharmacy Manager
Emory Decatur Hospital
4045015044 | 9/16/2020 10:51 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2019 10:46:08 AM | 9/16/2020 10:51:47 AM | 9/16/2020 10:51 AM |
| Details | Last Recertification Date | Update | Recertification | 9/5/2018 11:19:39 AM | 9/9/2019 10:46:08 AM | 9/9/2019 10:46 AM |
| Details | Entity Name | Update | Change Request | DEKALB MEDICAL CENTER, INC | DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL | 11/20/2018 3:51 PM |
| Details | Last Recertification Date | Update | Recertification | 12/5/2017 11:14:54 AM | 9/5/2018 11:19:39 AM | 9/5/2018 11:19 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Wilson, Bob
President and Chief Executive Officer
DeKalb Medical
4045015209 | Daunt-Samford, Liz
CFO
DeKalb Medical
4045015025 | 8/30/2018 10:28 AM |
| Details | Entity Name | Update | Recertification | DEKALB MEDICAL CENTER | DEKALB MEDICAL CENTER, INC | 12/5/2017 11:19 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | Wilson, Bob
Interim President and Chief Executive Officer
DeKalb Medical
4045015209 | Wilson, Bob
President and Chief Executive Officer
DeKalb Medical
4045015209 | 12/5/2017 11:18 AM |
| Contacts | Primary Contact | Update | Recertification | Kelvas, Martin
System Pharmacy Director
4045015561 | Mindel, Kristina
Pharmacy Manager
DeKalb Medical
4045015044 | 12/5/2017 11:14 AM |
| Details | Last Recertification Date | Update | Recertification | 8/10/2016 12:00:00 AM | 12/5/2017 11:14:54 AM | 12/5/2017 11:14 AM |
| Contacts | Authorizing Official | Update | | Wilson, Bob
Interim President and Chief Executive Officer
4045015209 | Wilson, Bob
Interim President and Chief Executive Officer
DeKalb Medical
4045015209 | 12/5/2017 11:08 AM |
| Contacts | Authorizing Official | Update | | SHELTON, JOHN
President and Chief Executive Officer
4045015209 | Wilson, Bob
Interim President and Chief Executive Officer
4045015209 | 9/11/2017 3:29 PM |
| Contacts | Authorizing Official | Insert | | | SHELTON, JOHN
President and Chief Executive Officer
4045015209 | 11/15/2016 4:32 PM |
| Contacts | Signed By | Insert | | | SHELTON, JOHN
President and Chief Executive Officer
4045015209 | 11/15/2016 4:32 PM |
| Contacts | Primary Contact | Insert | | | Kelvas, Martin
System Pharmacy Director
4045015561 | 11/15/2016 4:32 PM |
| Addresses | Main Address | Insert | | |
2675 North Decatur Rd
Suite G09
Decatur, GA 30033 | 8/10/2016 2:02 PM |
| Details | Last Recertification Date | Update | | | 8/10/2016 12:00:00 AM | 8/10/2016 2:02 PM |
| Dates | Participating Approval Date | Update | | | 10/6/2015 12:00:00 AM | 10/6/2015 5:33 PM |
| Details | State | Update | | Pending | Active | 10/6/2015 5:33 PM |
| Dates | Start Date | Update | | | 1/1/2016 12:00:00 AM | 10/6/2015 5:33 PM |
| Addresses | Billing Address | Insert | | | Dekalb Medical Center
2701 North Decatur Rd
Decatur, GA 30033 | 10/6/2015 5:33 PM |
| Addresses | Shipping Address | Insert | | | Dekalb Medical Center
2701 North Decatur Rd
Decatur, GA 30033 | 10/6/2015 5:33 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_54375 | DSH110076C | 10/6/2015 12:58 PM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_54375 | 10/2/2015 1:16 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/2/2015 1:16 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 000000536A | 10/2/2015 1:16 PM |
| Medicaid Billing | Medicaid: State | Insert | | | GA | 10/2/2015 1:16 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1093716979 | 10/2/2015 1:16 PM |
| Details | Last Recertification Date | Insert | | | | 10/2/2015 1:16 PM |
| Details | Grant Number | Insert | | | | 10/2/2015 1:16 PM |
| Details | 340B ID | Insert | | | | 10/2/2015 1:16 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/2/2015 1:16 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/2/2015 1:16 PM |
| Details | Medicare Provider Number | Insert | | | 110076 | 10/2/2015 1:16 PM |
| Details | Entity Name | Insert | | | DEKALB MEDICAL CENTER | 10/2/2015 1:16 PM |
| Details | Program Code | Insert | | | DSH | 10/2/2015 1:16 PM |
| Details | Entity Subname | Insert | | | Radiology Diagnostic | 10/2/2015 1:16 PM |
| Dates | Participating Approval Date | Insert | | | | 10/2/2015 1:16 PM |
| Details | State | Insert | | | Pending | 10/2/2015 1:16 PM |
| Dates | Registration Date | Insert | | | 10/2/2015 12:00:00 AM | 10/2/2015 1:16 PM |
| Dates | Signed By Date | Insert | | | 10/2/2015 12:00:00 AM | 10/2/2015 1:16 PM |
| Dates | Start Date | Insert | | | | 10/2/2015 1:16 PM |
| Terminations | Termination Comments | Insert | | | | 10/2/2015 1:16 PM |
| Terminations | Termination Date | Insert | | | | 10/2/2015 1:16 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/2/2015 1:16 PM |
| Terminations | Termination Reason | Insert | | | | 10/2/2015 1:16 PM |