| Details | State | Update | | To Be Terminated | Terminated | 4/1/2021 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 3/11/2020 12:00:00 AM | 2/23/2021 10:56 AM |
| Details | State | Update | Recertification | Active | To Be Terminated | 2/23/2021 10:56 AM |
| Terminations | Termination Date | Update | Recertification | | 4/1/2021 12:00:00 AM | 2/23/2021 10:56 AM |
| Terminations | Termination Effective Date | Update | Recertification | | 3/11/2020 12:00:00 AM | 2/23/2021 10:56 AM |
| Terminations | Termination Reason | Update | Recertification | | Site closure | 2/23/2021 10:56 AM |
| Contacts | Authorizing Official | Update | Change Request | Robinson, Angela
Health Program Manager
CINCINNATI HEALTH DEPARTMENT
5133577456 | Hopson, Domonic
ceo ccpc
City of Cincinnati HEALTH DEPARTMENT
5133577361 | 1/21/2021 9:27 AM |
| Contacts | Primary Contact | Update | Change Request | Blackley, Holly
Phamacy Director
City of Cincinnati HEALTH DEPARTMENT
5133166817 | mussman, grant
medical director
city of cincinnati health department
5133577215 | 1/21/2021 9:27 AM |
| Addresses | Shipping Address | Insert | Recertification | | Ambrose Health Center Pharmacy
3559 Reading Road
101
cincinnati, OH 45229 | 2/18/2020 2:04 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1477112308 | 2/18/2020 2:04 PM |
| Details | Last Recertification Date | Update | Recertification | 2/13/2019 8:34:29 AM | 2/18/2020 2:04:55 PM | 2/18/2020 2:04 PM |
| Addresses | Shipping Address | Insert | Change Request | | cann medical center pharmacy
5818 madison road
Cincinnati, OH 45227 | 4/30/2019 11:45 AM |
| Addresses | Shipping Address | Insert | Change Request | | elm street health center pharmacy
1525 elm st
cincinnati, OH 45202 | 4/30/2019 11:45 AM |
| Addresses | Shipping Address | Insert | Change Request | | millvale health center pharmacy
2750 beekman st
Cincinnati, OH 45225 | 4/30/2019 11:45 AM |
| Addresses | Shipping Address | Insert | Change Request | | northside health center pharmacy
3917 spring grove ave
Cincinnati, OH 45223 | 4/30/2019 11:45 AM |
| Addresses | Shipping Address | Insert | Change Request | | price hill health center pharmacy
2138 w 8 th street
cincinnati, OH 45204 | 4/30/2019 11:45 AM |
| Details | Last Recertification Date | Update | Recertification | 2/16/2018 5:17:22 PM | 2/13/2019 8:34:29 AM | 2/13/2019 8:34 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Tate, Joyce
Asst health commissioner/CEO
City Of Cincinnati Health Department
5133577361 | Robinson, Angela
Health Program Manager
CINCINNATI HEALTH DEPARTMENT
5133577456 | 2/11/2019 8:09 AM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 0511753 (OH) | | 2/16/2018 5:17 PM |
| Medicaid Billing | Medicaid: Number | Update | Recertification | 0511735 | 0511753 | 2/16/2018 5:17 PM |
| Medicaid Billing | Medicaid: Number | Delete | Recertification | 0155379 (OH) | | 2/16/2018 5:17 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/16/2018 5:17 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 0155379 | 2/16/2018 5:17 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | OH | 2/16/2018 5:17 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/16/2018 5:17 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 0511735 | 2/16/2018 5:17 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | OH | 2/16/2018 5:17 PM |
| Details | Last Recertification Date | Update | Recertification | 2/16/2017 12:00:00 AM | 2/16/2018 5:17:22 PM | 2/16/2018 5:17 PM |
| Details | Is Authorizing Official EHB Data | Update | Recertification | False | | 2/16/2018 5:17 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Blackley, Holly
Phamacy Director
City of Cincinnati HEALTH DEPARTMENT
5133169817 | Blackley, Holly
Phamacy Director
City of Cincinnati HEALTH DEPARTMENT
5133166817 | 1/12/2018 10:27 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Blackley, Holly
Staff Pharmacist/340B
CINCINNATI HEALTH DEPARTMENT
5133523094 | Blackley, Holly
Phamacy Director
City of Cincinnati HEALTH DEPARTMENT
5133169817 | 1/12/2018 10:23 AM |
| Contacts | Authorizing Official | Update | Change Request | Tate, Joyce
Asst health commissioner/CEO
5133577361 | Tate, Joyce
Asst health commissioner/CEO
City Of Cincinnati Health Department
5133577361 | 1/11/2018 4:11 PM |
| Contacts | Signed By | Update | Change Request | Tate, Joyce
Asst health commissioner/CEO
5133577361 | Tate, Joyce
Asst health commissioner/CEO
City Of Cincinnati Health Department
5133577361 | 1/11/2018 4:11 PM |
| Contacts | Primary Contact | Update | | Blackley, Holly
Staff Pharmacist/340B
5133523094 | Blackley, Holly
Staff Pharmacist/340B
CINCINNATI HEALTH DEPARTMENT
5133523094 | 11/30/2017 3:41 PM |
| Contacts | Authorizing Official | Insert | | | Tate, Joyce
Asst health commissioner/CEO
5133577361 | 5/3/2017 11:07 AM |
| Contacts | Signed By | Insert | | | Tate, Joyce
Asst health commissioner/CEO
5133577361 | 5/3/2017 11:07 AM |
| Addresses | Main Address | Insert | | |
1005 Walnut Street
Cincinnati, OH 45202-1109 | 2/16/2017 12:23 PM |
| Contacts | Primary Contact | Insert | | | Blackley, Holly
Staff Pharmacist/340B
5133523094 | 2/16/2017 12:23 PM |
| Details | Last Recertification Date | Update | | | 2/16/2017 12:00:00 AM | 2/16/2017 12:23 PM |
| Dates | Participating Approval Date | Update | | | 4/13/2016 12:00:00 AM | 4/13/2016 12:43 PM |
| Details | State | Update | | Pending | Active | 4/13/2016 12:43 PM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 4/13/2016 12:43 PM |
| Details | 340B ID | Update | | ONLINE_REG_59270 | CHC25683-20 | 4/12/2016 9:58 AM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_59270 | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 0511753 | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 0277034 | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 0274957 | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 0511735 | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 0274966 | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 0155379 | 4/7/2016 2:15 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OH | 4/7/2016 2:15 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1538243787 | 4/7/2016 2:15 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1316000920 | 4/7/2016 2:15 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1245314491 | 4/7/2016 2:15 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1063591949 | 4/7/2016 2:15 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1457435190 | 4/7/2016 2:15 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1760873921 | 4/7/2016 2:15 PM |
| Details | Last Recertification Date | Insert | | | | 4/7/2016 2:15 PM |
| Details | Grant Number | Insert | | | H80CS25683 | 4/7/2016 2:15 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 4/7/2016 2:15 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 4/7/2016 2:15 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/7/2016 2:15 PM |
| Details | Medicare Provider Number | Insert | | | | 4/7/2016 2:15 PM |
| Details | Entity Name | Insert | | | CINCINNATI, CITY OF | 4/7/2016 2:15 PM |
| Details | Program Code | Insert | | | CH | 4/7/2016 2:15 PM |
| Details | Entity Subname | Insert | | | Walnut Street Health Center | 4/7/2016 2:15 PM |
| Dates | Participating Approval Date | Insert | | | | 4/7/2016 2:15 PM |
| Details | State | Insert | | | Pending | 4/7/2016 2:15 PM |
| Dates | Registration Date | Insert | | | 4/7/2016 12:00:00 AM | 4/7/2016 2:15 PM |
| Dates | Signed By Date | Insert | | | 4/7/2016 12:00:00 AM | 4/7/2016 2:15 PM |
| Dates | Start Date | Insert | | | | 4/7/2016 2:15 PM |
| Terminations | Termination Comments | Insert | | | | 4/7/2016 2:15 PM |
| Terminations | Termination Date | Insert | | | | 4/7/2016 2:15 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/7/2016 2:15 PM |
| Terminations | Termination Reason | Insert | | | | 4/7/2016 2:15 PM |