Covered Entity Details

DSH150113 COMMUNITY HOSPITAL ANDERSON (Active) - information as of 5/5/2025 10:03:24 PM

Main Details

Name

COMMUNITY HOSPITAL ANDERSON

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH150113

Medicare Provider Number

150113

Additional Details

Current Program Status

Active

Registration Date

1/7/2021

Participating Start Date

4/1/2021

Participating Approval Date

3/3/2021

Last Recertification Date

8/12/2024

Contacts

Authorizing Official

Community Health Network
Beth Tharp, SVP/President of Hospital Services
(765) 298-5125

Primary Contact

Community Health Network
Ashley Marie Harlow, Director, 340B and Strategic Pharmacy Revenue
(317) 621-1791

Addresses

Street Address

1515 NORTH MADISON AVE
ANDERSON, IN 46011

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting 7/1/2016, terminated 10/1/2020. Reinstated 4/1/2021.	02/02/2021

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	AVELLA OF ST LOUIS	450 N NEW BALLAS RD STE 256		SAINT LOUIS	MO	63141-6836	04/12/2019	07/01/2019	08/01/2020	08/01/2020
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	COMMUNITY HOSPITAL NORTH SPECIALTY PHARM	DBA COMMUNITY HEALTH NETWORK SPECIALTY P	7250 CLEARVISTA DR STE 140	INDIANAPOLIS	IN	46256	01/14/2019	04/01/2019	10/01/2020	10/01/2020
Contract Detail	COMMUNITY HOSPITAL NORTH SPECIALTY PHARM	DBA COMMUNITY HEALTH NETWORK SPECIALTY P	7250 CLEARVISTA DR STE 140	INDIANAPOLIS	IN	46256	01/07/2022	01/10/2022		01/10/2022
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	11711 NORTH COLLEGE AVENUE SUITE 125	CARMEL	IN	46032-5601	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	431 FERNHILL AVENUE	FORT WAYNE	IN	46805	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	CORAM HEALTHCARE CORPORATION OF INDIANA	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	1290 ARROWHEAD COURT SUITE A	CROWN POINT	IN	46307	10/15/2018	01/01/2019	01/01/2019	01/14/2019
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	10/15/2018	01/01/2019	02/03/2020	04/22/2020
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	04/12/2019	07/01/2019	08/01/2020	08/01/2020
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	10/15/2018	01/01/2019	02/01/2020	02/11/2020
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06618	105 NORTH PARK AVE	ALEXANDRIA	IN	46001	10/15/2018	01/01/2019	10/01/2020	10/01/2020
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06617	100 N ANDERSON ST.	ELWOOD	IN	46036	10/15/2018	01/01/2019	10/01/2020	10/01/2020
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06617	100 N ANDERSON ST.	ELWOOD	IN	46036	10/04/2021	01/01/2022	09/01/2023	09/01/2023
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06656	3824 MAIN STREET	ANDERSON	IN	46013	10/04/2021	01/01/2022	09/01/2023	09/01/2023
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06638	2419 NICHOL AVE	ANDERSON	IN	46016	10/04/2021	01/01/2022	09/01/2023	09/01/2023
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06662	711 W. MILL ST.	MIDDLETOWN	IN	47356	10/04/2021	01/01/2022	09/01/2023	09/01/2023
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06640	265 SO. SCATTERFIELD RD	ANDERSON	IN	46012	10/04/2021	01/01/2022	09/01/2023	09/01/2023
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06618	105 NORTH PARK AVE	ALEXANDRIA	IN	46001	10/04/2021	01/01/2022	06/17/2024	07/12/2024
Contract Detail	HOOK-SUPERX, L.L.C.	DBA: CVS/PHARMACY # 06651	2003 BROADWAY	ANDERSON	IN	46012	10/04/2021	01/01/2022	09/01/2023	09/01/2023
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/12/2019	07/01/2019	08/01/2020	08/01/2020
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	10/15/2018	01/01/2019	02/03/2020	04/22/2020
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/14/2019	04/01/2019	04/27/2020	04/30/2020
Contract Detail	WALGREEN CO	DBA: WALGREENS #10533	3250 N MORRISON ROAD	MUNCIE	IN	47304	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS #16558	1400 N RITTER AVE. SUITE 140	INDIANAPOLIS	IN	46219	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS #16559	7120 CLEARVISTA DR. SUITE 1900	INDIANAPOLIS	IN	46256	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05803	2720 W JACKSON	MUNCIE	IN	47303	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS SPECIALTY PHARMACY #16317	335 MASSACHUSETTS AVENUE	INDIANAPOLIS	IN	46204	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07788	320 S SCATTERFIELD RD	ANDERSON	IN	46012-3601	10/15/2018	01/01/2019	10/01/2020	10/01/2020
Contract Detail	WALGREEN CO.	WALGREENS #16557	1550 E. COUNTY LINE ROAD SUITE 150	INDIANAPOLIS	IN	46227	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06761	3736 S SCATTERFIELD RD	ANDERSON	IN	46013	10/15/2018	01/01/2019	10/01/2020	10/01/2020
Contract Detail	WALGREEN CO.	W002 DBA: WALGREENS #07690	100 N. MEMORIAL DR	NEW CASTLE	IN	47362	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07788	320 S SCATTERFIELD RD	ANDERSON	IN	46012-3601	04/07/2022	07/01/2022	04/12/2024	04/12/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06761	3736 S SCATTERFIELD RD	ANDERSON	IN	46013	04/07/2022	07/01/2022	04/12/2024	04/12/2024
Contract Detail	Walgreens Central Fill #21399	4132Plainfield Rd	Ste 110	Indianapolis	IN	46231-7021	01/17/2023	04/01/2023	04/12/2024	04/12/2024
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	10/15/2018	01/01/2019	02/03/2020	02/06/2020
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	10/15/2018	01/01/2019	02/03/2020	02/06/2020

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH150113A	Child	DSH	COMMUNITY HOSPITAL ANDERSON	COMMUNITY HOSPITAL ANDERSON OUTPATI - Outpatient Imaging Center	1130 MEDICAL ARTS BLVD	ANDERSON	IN	Terminated
DSH150113B	Child	DSH	COMMUNITY HOSPITAL ANDERSON	COMMUNITY HOSPITAL ANDERSON HEALTHY - Healthy Hearts Clinic	1210 MEDICAL ARTS BLVD	ANDERSON	IN	Terminated
DSH150113C	Child	DSH	COMMUNITY HOSPITAL ANDERSON	COMMUNITY HOSPITAL ANDERSON RADIATI - Radiation Oncology	1340 N MADISON AVE	ANDERSON	IN	Active
DSH150113D	Child	DSH	COMMUNITY HOSPITAL ANDERSON	COMMUNITY HOSPITAL ANDERSON ANTICOA - Anti-coagulation Clinic	1210B MEDICAL ARTS BLVD	ANDERSON	IN	Active
DSH150113E	Child	DSH	COMMUNITY HOSPITAL ANDERSON	COMMUNITY HOSPITAL ANDERSON HEALTHY - Heart Failure	1210B MEDICAL ARTS BLVD	ANDERSON	IN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/14/2023 11:58:27 AM	8/12/2024 11:55:46 AM	8/12/2024 11:55 AM
Contacts	Primary Contact	Update	Profile Change Request	Harlow, Ashley Marie 340B Pharmacy Manager Community Health Network 3176211791	Harlow, Ashley Marie Director, 340B and Strategic Pharmacy Revenue Community Health Network 3176211791	9/12/2023 9:06 AM
Details	Last Recertification Date	Update	Recertification	8/31/2022 12:44:03 PM	8/14/2023 11:58:27 AM	8/14/2023 11:58 AM
Details	Last Recertification Date	Update	Recertification	8/19/2021 10:04:44 AM	8/31/2022 12:44:03 PM	8/31/2022 12:44 PM
Contacts	Authorizing Official	Update	Profile Change Request	Tharp, Beth President & CEO Community Hospital Anderson 7652985125	Tharp, Beth SVP/President of Hospital Services Community Health Network 7652985125	2/16/2022 4:17 PM
Contacts	Signed By	Update	Profile Change Request	Tharp, Beth President & CEO Community Hospital Anderson 7652985125	Tharp, Beth SVP/President of Hospital Services Community Health Network 7652985125	2/16/2022 4:17 PM
Details	Last Recertification Date	Update	Recertification		8/19/2021 10:04:44 AM	8/19/2021 10:04 AM
Details	State	Update		Approved	Active	4/1/2021 12:01 AM
Contacts	Primary Contact	Update	Reinstatement	Bahrami, Homand Pharmacy Director Community Hospital of Anderson 7652982427	Harlow, Ashley Marie 340B Pharmacy Manager Community Health Network 3176211791	3/3/2021 4:03 PM
Details	Last Recertification Date	Update	Reinstatement	8/28/2019 9:24:17 AM		3/3/2021 4:03 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	8/27/2020 12:00:00 AM		3/3/2021 4:03 PM
Dates	Participating Approval Date	Update	Reinstatement	5/5/2016 12:00:00 AM	3/3/2021 4:03:35 PM	3/3/2021 4:03 PM
Details	State	Update	Reinstatement	Terminated	Approved	3/3/2021 4:03 PM
Dates	Registration Date	Update	Reinstatement	4/8/2016 12:00:00 AM	1/7/2021 11:03:24 AM	3/3/2021 4:03 PM
Dates	Signed By Date	Update	Reinstatement	4/8/2016 12:00:00 AM	1/22/2021 9:26:42 AM	3/3/2021 4:03 PM
Dates	Start Date	Update	Reinstatement	7/1/2016 12:00:00 AM	4/1/2021 12:00:00 AM	3/3/2021 4:03 PM
Terminations	Termination Date	Update	Reinstatement	10/1/2020 12:00:00 AM		3/3/2021 4:03 PM
Terminations	Termination Effective Date	Update	Reinstatement	8/31/2020 12:00:00 AM		3/3/2021 4:03 PM
Terminations	Termination Reason	Update	Reinstatement	DSH percentage below statutory minimum		3/3/2021 4:03 PM
Details	Comments Public	Insert	Reinstatement		Participated starting 7/1/2016, terminated 10/1/2020. Reinstated 4/1/2021.	2/2/2021 8:57 AM
Details	State	Update		To Be Terminated	Terminated	10/1/2020 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		8/27/2020 12:00:00 AM	9/4/2020 11:14 PM
Details	State	Update	Recertification	Active	To Be Terminated	9/4/2020 11:14 PM
Terminations	Termination Date	Update	Recertification		10/1/2020 12:00:00 AM	9/4/2020 11:14 PM
Terminations	Termination Effective Date	Update	Recertification		8/31/2020 12:00:00 AM	9/4/2020 11:14 PM
Terminations	Termination Reason	Update	Recertification		DSH percentage below statutory minimum	9/4/2020 11:14 PM
Details	Last Recertification Date	Update	Recertification	8/17/2018 9:21:45 AM	8/28/2019 9:24:17 AM	8/28/2019 9:24 AM
Details	Last Recertification Date	Update	Recertification	11/8/2017 12:31:45 PM	8/17/2018 9:21:45 AM	8/17/2018 9:21 AM
Details	Last Recertification Date	Update	Recertification	8/11/2016 12:00:00 AM	11/8/2017 12:31:45 PM	11/8/2017 12:31 PM
Contacts	Authorizing Official	Update		Tharp, Beth President & CEO 7652985125	Tharp, Beth President & CEO Community Hospital Anderson 7652985125	9/25/2017 7:26 PM
Contacts	Signed By	Update		Tharp, Beth President & CEO 7652985125	Tharp, Beth President & CEO Community Hospital Anderson 7652985125	9/25/2017 7:26 PM
Contacts	Primary Contact	Update		Bahrami, Homand Pharmacy Director 7652982427	Bahrami, Homand Pharmacy Director Community Hospital of Anderson 7652982427	9/21/2017 4:50 PM
Addresses	Main Address	Insert			1515 NORTH MADISON AVE ANDERSON, IN 46011	8/16/2016 4:27 PM
Contacts	Primary Contact	Insert			Bahrami, Homand Pharmacy Director 7652982427	8/16/2016 4:27 PM
Contacts	Authorizing Official	Insert			Tharp, Beth President & CEO 7652985125	8/16/2016 4:27 PM
Contacts	Signed By	Insert			Tharp, Beth President & CEO 7652985125	8/16/2016 4:27 PM
Details	Last Recertification Date	Update			8/11/2016 12:00:00 AM	8/16/2016 4:27 PM
Dates	Participating Approval Date	Update			5/5/2016 12:00:00 AM	5/5/2016 3:26 PM
Details	State	Update		Pending	Active	5/5/2016 3:26 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	5/5/2016 3:26 PM
Details	340B ID	Update		ONLINE_REG_59397	DSH150113	5/4/2016 11:50 AM
Details	340B ID	Update			ONLINE_REG_59397	4/8/2016 4:39 PM
Details	Last Recertification Date	Insert				4/8/2016 4:39 PM
Details	Grant Number	Insert				4/8/2016 4:39 PM
Details	340B ID	Insert				4/8/2016 4:39 PM
Details	Is Authorizing Official EHB Data	Insert				4/8/2016 4:39 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/8/2016 4:39 PM
Details	Medicare Provider Number	Insert			150113	4/8/2016 4:39 PM
Details	Entity Name	Insert			COMMUNITY HOSPITAL ANDERSON	4/8/2016 4:39 PM
Details	Program Code	Insert			DSH	4/8/2016 4:39 PM
Details	Entity Subname	Insert				4/8/2016 4:39 PM
Dates	Participating Approval Date	Insert				4/8/2016 4:39 PM
Details	State	Insert			Pending	4/8/2016 4:39 PM
Dates	Registration Date	Insert			4/8/2016 12:00:00 AM	4/8/2016 4:39 PM
Dates	Signed By Date	Insert			4/8/2016 12:00:00 AM	4/8/2016 4:39 PM
Dates	Start Date	Insert				4/8/2016 4:39 PM
Terminations	Termination Comments	Insert				4/8/2016 4:39 PM
Terminations	Termination Date	Insert				4/8/2016 4:39 PM
Terminations	Termination Effective Date	Insert				4/8/2016 4:39 PM
Terminations	Termination Reason	Insert				4/8/2016 4:39 PM