| Details | State | Update | | To Be Terminated | Terminated | 1/1/2023 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 9/13/2022 12:00:00 AM | 10/31/2022 8:22 AM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 10/31/2022 8:22 AM |
| Terminations | Termination Date | Update | Termination Request | | 1/1/2023 12:00:00 AM | 10/31/2022 8:22 AM |
| Terminations | Termination Effective Date | Update | Termination Request | | 9/26/2022 12:00:00 AM | 10/31/2022 8:22 AM |
| Terminations | Termination Reason | Update | Termination Request | | Site closure | 10/31/2022 8:22 AM |
| Addresses | Billing Address | Update | Group Change Request | Primary Health Care Center of Dade, Inc.
25 Quartermaster Circle
Ft. Oglethorpe, GA 30742 | Primary Health Care Center of Dade, Inc.
100 Mitchell Road
Fort Oglethorpe, GA 30742 | 8/3/2022 11:05 AM |
| Addresses | Billing Address | Insert | Group Change Request | | Primary Health Care Center of Dade, Inc.
25 Quartermaster Circle
Ft. Oglethorpe, GA 30742 | 7/11/2022 10:49 AM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2021 1:22:48 PM | 2/18/2022 3:39:16 PM | 2/18/2022 3:39 PM |
| Details | Last Recertification Date | Update | Recertification | 1/29/2020 2:30:17 PM | 2/3/2021 1:22:48 PM | 2/3/2021 1:22 PM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2019 9:43:42 AM | 1/29/2020 2:30:17 PM | 1/29/2020 2:30 PM |
| Details | Last Recertification Date | Update | Recertification | 2/12/2018 9:50:28 AM | 1/30/2019 9:43:42 AM | 1/30/2019 9:43 AM |
| Addresses | Main Address | Update | Change Request |
106 E. Withers Street
Lafayette, GA 30728-2576 |
205 Jenkins Road
Rossville, GA 30741-4016 | 9/13/2018 7:27 AM |
| Details | Entity Subname | Update | Change Request | Primary Health Care Center Lafayette (Administrative Only) | Primary Healthcare Centers-Fairview (Administrative Only) | 9/13/2018 7:27 AM |
| Contacts | Primary Contact | Update | Recertification | ALLEN, DIANA U.
CEO
Primary Health Care Center of Dade, Inc.
7066204494-8549 | Forsythe, Melanie
COO
Primary Health Care Center of Dade, Inc.
7066204494-8541 | 2/12/2018 9:50 AM |
| Details | Last Recertification Date | Update | Recertification | 2/15/2017 12:00:00 AM | 2/12/2018 9:50:28 AM | 2/12/2018 9:50 AM |
| Details | Is Authorizing Official EHB Data | Update | Recertification | False | | 2/12/2018 9:50 AM |
| Contacts | Authorizing Official | Update | | ALLEN, DIANA U.
CEO
7066204494-8549 | ALLEN, DIANA U.
CEO
Primary Health Care Center of Dade, Inc.
7066204494-8549 | 2/12/2018 9:39 AM |
| Contacts | Primary Contact | Update | | ALLEN, DIANA U.
CEO
7066204494-8549 | ALLEN, DIANA U.
CEO
Primary Health Care Center of Dade, Inc.
7066204494-8549 | 2/12/2018 9:39 AM |
| Contacts | Signed By | Update | | ALLEN, DIANA U.
CEO
7066204494-8549 | ALLEN, DIANA U.
CEO
Primary Health Care Center of Dade, Inc.
7066204494-8549 | 2/12/2018 9:39 AM |
| Contacts | Authorizing Official | Insert | | | ALLEN, DIANA U.
CEO
7066204494-8549 | 4/11/2017 10:18 AM |
| Contacts | Primary Contact | Insert | | | ALLEN, DIANA U.
CEO
7066204494-8549 | 4/11/2017 10:18 AM |
| Contacts | Signed By | Insert | | | ALLEN, DIANA U.
CEO
7066204494-8549 | 4/11/2017 10:18 AM |
| Addresses | Main Address | Insert | | |
106 E. Withers Street
Lafayette, GA 30728-2576 | 2/15/2017 10:02 AM |
| Details | Last Recertification Date | Update | | | 2/15/2017 12:00:00 AM | 2/15/2017 10:02 AM |
| Dates | Participating Approval Date | Update | | | 2/10/2016 12:00:00 AM | 2/10/2016 5:22 PM |
| Details | State | Update | | Pending | Active | 2/10/2016 5:22 PM |
| Dates | Start Date | Update | | | 4/1/2016 12:00:00 AM | 2/10/2016 5:22 PM |
| Details | 340B ID | Update | | ONLINE_REG_58008 | CH04479D | 2/2/2016 12:03 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_58008 | 1/14/2016 2:15 PM |
| Details | Last Recertification Date | Insert | | | | 1/14/2016 2:15 PM |
| Details | Grant Number | Insert | | | H80CS00649 | 1/14/2016 2:15 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 1/14/2016 2:15 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 1/14/2016 2:15 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 1/14/2016 2:15 PM |
| Details | Medicare Provider Number | Insert | | | | 1/14/2016 2:15 PM |
| Details | Entity Name | Insert | | | PRIMARY HEALTH CARE CENTER OF DADE, INC. | 1/14/2016 2:15 PM |
| Details | Program Code | Insert | | | CH | 1/14/2016 2:15 PM |
| Details | Entity Subname | Insert | | | Primary Health Care Center Lafayette (Administrative Only) | 1/14/2016 2:15 PM |
| Dates | Participating Approval Date | Insert | | | | 1/14/2016 2:15 PM |
| Details | State | Insert | | | Pending | 1/14/2016 2:15 PM |
| Dates | Registration Date | Insert | | | 1/14/2016 12:00:00 AM | 1/14/2016 2:15 PM |
| Dates | Signed By Date | Insert | | | 1/14/2016 12:00:00 AM | 1/14/2016 2:15 PM |
| Dates | Start Date | Insert | | | | 1/14/2016 2:15 PM |
| Terminations | Termination Comments | Insert | | | | 1/14/2016 2:15 PM |
| Terminations | Termination Date | Insert | | | | 1/14/2016 2:15 PM |
| Terminations | Termination Effective Date | Insert | | | | 1/14/2016 2:15 PM |
| Terminations | Termination Reason | Insert | | | | 1/14/2016 2:15 PM |