Covered Entity Details

DSH340130D Atrium Health Union (Terminated) - information as of 4/27/2025 12:51:15 AM

Main Details

Name

Atrium Health Union

Subdivision Name

Levine Cancer Institute / Medical Oncology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH340130D

Medicare Provider Number

340130

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/14/2016

Participating Start Date

7/1/2016

Participating Approval Date

5/5/2016

Last Recertification Date

9/9/2021

Termination Date
Termination Reason

4/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Atrium Health
Don McCoy Mabe, VP, Pharmacy
(704) 512-7623

Primary Contact

Atrium Health
Fern Paul-Aviles, AVP, Pharmacy
(704) 649-9691

Addresses

Street Address

1550 Faulk Street
Suites 1500 and 2200
Monroe, NC 28112

Billing Address

Atrium Health Accounts Payable
PO Box 5379
Portland, OR 97228-5379

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
SC	222151
AZ	573712
GA	003228777A
KY	7100628380
NM	39185583
TN	Q056819
CO	9000185037
FL	910602200
NY	01853630
NC		1396790325
WI		1396790325

Shipping Addresses

Same as Street Address

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
DSH340130A	Child	DSH	ATRIUM HEALTH UNION	Atrium Health Pain Management, a facility of Atrium Health Union	355 Venus St	Monroe	NC	Terminated
DSH340130B	Child	DSH	ATRIUM HEALTH UNION	Atrium Health Waxhaw, a facility of Atrium Health Union	2700 Providence Road, South	Waxhaw	NC	Terminated
DSH340130C	Child	DSH	Atrium Health Union	Levine Cancer Institute / Infusion Center	1550 Faulk Street	Monroe	NC	Terminated
DSH340130D	Child	DSH	Atrium Health Union	Levine Cancer Institute / Medical Oncology	1550 Faulk Street	Monroe	NC	Terminated
DSH340130E	Child	DSH	ATRIUM HEALTH UNION	Levine Cancer Institute Radiation Oncology	600 Hospital Drive	Monroe	NC	Terminated
DSH340130F	Child	DSH	ATRIUM HEALTH UNION	Atrium Health Union West - Emergency Department (1117.10839.30001)	1000 Healing Way	Matthews	NC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	Mabe, Don McCoy VP, Pharmacy Atrium Health 7045127623	8/13/2024 2:16 PM
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/3/2021 12:00:00 AM	3/28/2022 12:00 PM
Details	State	Update	Termination Request	Active	To Be Terminated	3/28/2022 12:00 PM
Terminations	Termination Date	Update	Termination Request		4/1/2022 12:00:00 AM	3/28/2022 12:00 PM
Terminations	Termination Effective Date	Update	Termination Request		12/4/2021 12:00:00 AM	3/28/2022 12:00 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	3/28/2022 12:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/13/2021 9:43 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		9000185037	9/13/2021 9:43 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		CO	9/13/2021 9:43 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0017296560003 (PA)		9/13/2021 9:43 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0340130 (VT)		9/13/2021 9:43 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1396790325 (VA)		9/13/2021 9:43 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1396790325	9/13/2021 9:43 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WI	9/13/2021 9:43 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 4:20:25 PM	9/9/2021 4:42:41 PM	9/9/2021 4:42 PM
Medicaid Billing	Medicaid: Number	Update		0017296560003	0017296560003	12/10/2020 4:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		573712	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003228777A	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		7100628380	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		39185583	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		Q056819	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/11/2020 4:20 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	3400130 (NC)		9/11/2020 4:20 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1396790325	9/11/2020 4:20 PM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/11/2020 4:20 PM
Medicaid Billing	NPI: State	Update	Recertification		VA	9/11/2020 4:20 PM
Contacts	Primary Contact	Update	Recertification	Paul-Aviles, Fern Assistant Vice President, Pharmacy Atrium Health 7046499691	Paul-Aviles, Fern AVP, Pharmacy Atrium Health 7046499691	9/11/2020 4:20 PM
Details	Last Recertification Date	Update	Recertification	9/10/2019 6:04:08 PM	9/11/2020 4:20:25 PM	9/11/2020 4:20 PM
Contacts	Authorizing Official	Update	AO Change Request	Haynes, Ken President and Executive Vice President Atrium Health 7043556305	Mabe, Don McCoy Chief Pharmacy Officer Atrium Health 7045127623	8/14/2020 7:58 AM
Contacts	Authorizing Official	Update	AO Change Request	Leighty, Scott Senior Vice President Carolinas HealthCare System 7045122414	Haynes, Ken President and Executive Vice President Atrium Health 7043556305	6/3/2020 7:15 AM
Contacts	Primary Contact	Update	Profile Change Request	Paul-Aviles, Fern Pharmacy Director Carolinas HealthCare System 7046499691	Paul-Aviles, Fern Assistant Vice President, Pharmacy Atrium Health 7046499691	9/12/2019 2:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2019 6:04 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		222151	9/10/2019 6:04 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/10/2019 6:04 PM
Details	Last Recertification Date	Update	Recertification	9/4/2018 1:42:10 PM	9/10/2019 6:04:08 PM	9/10/2019 6:04 PM
Details	Entity Name	Update	Change Request	Carolinas HealthCare System Union	Atrium Health Union	2/28/2019 9:06 AM
Addresses	Main Address	Update	Change Request	1550 Faulk Street Suite 2200 Monroe, NC 28112	1550 Faulk Street Suites 1500 and 2200 Monroe, NC 28112	2/20/2019 12:59 PM
Addresses	Billing Address	Update	Change Request	Carolinas HealthCare System Accounts Payable PO Box 5379 Portland, OR 97228-5379	Atrium Health Accounts Payable PO Box 5379 Portland, OR 97228-5379	2/20/2019 12:59 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 8:30:26 PM	9/4/2018 1:42:10 PM	9/4/2018 1:42 PM
Addresses	Billing Address	Update	Recertification	Accounts Payable PO Box 37972 Charlotte, NC 28237	Carolinas HealthCare System Accounts Payable PO Box 5379 Portland, OR 97228-5379	11/29/2017 8:30 PM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/29/2017 8:30:26 PM	11/29/2017 8:30 PM
Details	Entity Name	Update	Recertification	UNION REGIONAL MEDICAL CENTER	Carolinas HealthCare System Union	11/29/2017 8:27 PM
Contacts	Authorizing Official	Update		Leighty, Scott Senior Vice President 7045122414	Leighty, Scott Senior Vice President Carolinas HealthCare System 7045122414	10/12/2017 9:08 AM
Contacts	Primary Contact	Update		Paul-Aviles, Fern Pharmacy Director 7046499691	Paul-Aviles, Fern Pharmacy Director Carolinas HealthCare System 7046499691	9/22/2017 2:54 PM
Contacts	Primary Contact	Insert			Paul-Aviles, Fern Pharmacy Director 7046499691	7/25/2017 1:24 PM
Contacts	Authorizing Official	Insert			Leighty, Scott Senior Vice President 7045122414	7/25/2017 1:24 PM
Contacts	Signed By	Insert			Knox, John J. Chief Administrative Officer 7043551116	7/25/2017 1:24 PM
Addresses	Main Address	Insert			1550 Faulk Street Suite 2200 Monroe, NC 28112	4/11/2017 2:53 PM
Addresses	Billing Address	Insert			Accounts Payable PO Box 37972 Charlotte, NC 28237	4/11/2017 2:53 PM
Details	Last Recertification Date	Update			8/31/2016 12:00:00 AM	8/31/2016 9:47 AM
Dates	Participating Approval Date	Update			5/5/2016 12:00:00 AM	5/5/2016 2:43 PM
Details	State	Update		Pending	Active	5/5/2016 2:43 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	5/5/2016 2:43 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_60381	DSH340130D	5/3/2016 10:31 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_60381	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Number	Insert			3400130	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: State	Insert			NC	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Number	Insert			910602200	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: State	Insert			FL	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Number	Insert			01853630	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: State	Insert			NY	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Number	Insert			0017296560003	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: State	Insert			PA	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: Number	Insert			0340130	4/14/2016 7:52 PM
Medicaid Billing	Medicaid: State	Insert			VT	4/14/2016 7:52 PM
Medicaid Billing	NPI: Number	Insert			1396790325	4/14/2016 7:52 PM
Details	Last Recertification Date	Insert				4/14/2016 7:52 PM
Details	Grant Number	Insert				4/14/2016 7:52 PM
Details	340B ID	Insert				4/14/2016 7:52 PM
Details	Is Authorizing Official EHB Data	Insert				4/14/2016 7:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/14/2016 7:52 PM
Details	Medicare Provider Number	Insert			340130	4/14/2016 7:52 PM
Details	Entity Name	Insert			UNION REGIONAL MEDICAL CENTER	4/14/2016 7:52 PM
Details	Program Code	Insert			DSH	4/14/2016 7:52 PM
Details	Entity Subname	Insert			Levine Cancer Institute / Medical Oncology	4/14/2016 7:52 PM
Dates	Participating Approval Date	Insert				4/14/2016 7:52 PM
Details	State	Insert			Pending	4/14/2016 7:52 PM
Dates	Registration Date	Insert			4/14/2016 12:00:00 AM	4/14/2016 7:52 PM
Dates	Signed By Date	Insert			4/14/2016 12:00:00 AM	4/14/2016 7:52 PM
Dates	Start Date	Insert				4/14/2016 7:52 PM
Terminations	Termination Comments	Insert				4/14/2016 7:52 PM
Terminations	Termination Date	Insert				4/14/2016 7:52 PM
Terminations	Termination Effective Date	Insert				4/14/2016 7:52 PM
Terminations	Termination Reason	Insert				4/14/2016 7:52 PM