| Details | State | Update | | To Be Terminated | Terminated | 4/1/2023 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 1/1/2023 12:00:00 AM | 1/19/2023 10:11 AM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 1/19/2023 10:11 AM |
| Terminations | Termination Comments | Update | Termination Request | | This site will remain eligible for 340B drugs and 340B purchases because it just moved within 4 walls. | 1/19/2023 10:11 AM |
| Terminations | Termination Date | Update | Termination Request | | 4/1/2023 12:00:00 AM | 1/19/2023 10:11 AM |
| Terminations | Termination Effective Date | Update | Termination Request | | 1/1/2023 12:00:00 AM | 1/19/2023 10:11 AM |
| Terminations | Termination Reason | Update | Termination Request | | Outpatient facility moved within the 4 walls of the parent hospital | 1/19/2023 10:11 AM |
| Addresses | Main Address | Update | Change Request |
21 BELMONT AVE
BRATTLEBORO, VT 05301-7110 |
17 Belmont Ave
Ron Reed Pavilion
2401
BRATTLEBORO, VT 05301 | 11/3/2022 1:34 PM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2021 9:55:21 AM | 9/12/2022 9:40:43 AM | 9/12/2022 9:40 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Bissonnette, Andre
CFO
Brattleboro Memorial Hospital
8022518716 | Griffey, Jennifer
Chief Financial Officer
Brattleboro Memorial Hospital
8022578716 | 9/2/2022 7:03 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Rogers, Michael
Vice President, Finance
Brattleboro Memorial Hospital
8022578279 | Bissonnette, Andre
CFO
Brattleboro Memorial Hospital
8022518716 | 11/2/2021 12:00 PM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2020 8:13:54 AM | 9/9/2021 9:55:21 AM | 9/9/2021 9:55 AM |
| Details | Entity Subname | Update | Change Request | BRATTLEBORO OBSTETRICS AND GYNECOLO | FOUR SEASONS OBGYN AND MIDWIFERY | 5/13/2021 8:59 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | VT | 8/28/2020 8:13 AM |
| Contacts | Primary Contact | Update | Recertification | Auger, Deanna
Certified Pharmacy Technician
Brattleboro Memorial Hospital
8022578267 | Gonthier, Shelly
340B Program Coordinator
Brattleboro Memorial Hospital
8022578267 | 8/28/2020 8:13 AM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2019 9:15:06 AM | 8/28/2020 8:13:54 AM | 8/28/2020 8:13 AM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2018 11:15:29 AM | 8/22/2019 9:15:06 AM | 8/22/2019 9:15 AM |
| Details | Last Recertification Date | Update | Recertification | 11/13/2017 1:11:58 PM | 8/20/2018 11:15:29 AM | 8/20/2018 11:15 AM |
| Details | Last Recertification Date | Update | Recertification | | 11/13/2017 1:11:58 PM | 11/13/2017 1:11 PM |
| Details | Entity Name | Update | Recertification | BRATTLEBORO MEMORIAL HOSPITAL | Brattleboro Memorial Hospital | 10/24/2017 12:11 PM |
| Contacts | Primary Contact | Update | Recertification | Auger, Deanna
Certified Pharmacy Technician
8022578267 | Auger, Deanna
Certified Pharmacy Technician
Brattleboro Memorial Hospital
8022578267 | 10/24/2017 12:09 PM |
| Contacts | Authorizing Official | Update | | Rogers, Michael
Vice President, Finance
8022578279 | Rogers, Michael
Vice President, Finance
Brattleboro Memorial Hospital
8022578279 | 10/5/2017 12:57 PM |
| Contacts | Signed By | Update | | Rogers, Michael
Vice President, Finance
8022578279 | Rogers, Michael
Vice President, Finance
Brattleboro Memorial Hospital
8022578279 | 10/5/2017 12:57 PM |
| Contacts | Authorizing Official | Insert | | | Rogers, Michael
Vice President, Finance
8022578279 | 2/3/2017 10:55 AM |
| Contacts | Signed By | Insert | | | Rogers, Michael
Vice President, Finance
8022578279 | 2/3/2017 10:55 AM |
| Contacts | Primary Contact | Update | | Rovella, Robert
Director, Finance
8022578330 | Auger, Deanna
Certified Pharmacy Technician
8022578267 | 2/3/2017 10:55 AM |
| Addresses | Main Address | Insert | | |
21 BELMONT AVE
BRATTLEBORO, VT 05301-7110 | 2/3/2017 10:54 AM |
| Addresses | Billing Address | Insert | | | Brattleboro Memorial Hospital
17 Belmont Avenue
Brattleboro, VT 05301 | 2/3/2017 10:54 AM |
| Addresses | Shipping Address | Insert | | | Brattleboro Memorial Hospital
17 Belmont Avenue
Brattleboro, VT 05301 | 2/3/2017 10:54 AM |
| Contacts | Primary Contact | Insert | | | Rovella, Robert
Director, Finance
8022578330 | 8/23/2016 12:10 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1306849708 | 8/23/2016 12:09 PM |
| Dates | Participating Approval Date | Update | | | 8/18/2016 12:00:00 AM | 8/18/2016 6:10 PM |
| Details | State | Update | | Pending | Active | 8/18/2016 6:10 PM |
| Dates | Start Date | Update | | | 10/1/2016 12:00:00 AM | 8/18/2016 6:10 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_70942 | DSH470011F | 7/15/2016 9:59 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_70942 | 7/5/2016 3:05 PM |
| Details | Last Recertification Date | Insert | | | | 7/5/2016 3:05 PM |
| Details | Grant Number | Insert | | | | 7/5/2016 3:05 PM |
| Details | 340B ID | Insert | | | | 7/5/2016 3:05 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 7/5/2016 3:05 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 7/5/2016 3:05 PM |
| Details | Medicare Provider Number | Insert | | | 470011 | 7/5/2016 3:05 PM |
| Details | Entity Name | Insert | | | BRATTLEBORO MEMORIAL HOSPITAL | 7/5/2016 3:05 PM |
| Details | Program Code | Insert | | | DSH | 7/5/2016 3:05 PM |
| Details | Entity Subname | Insert | | | BRATTLEBORO OBSTETRICS AND GYNECOLO | 7/5/2016 3:05 PM |
| Dates | Participating Approval Date | Insert | | | | 7/5/2016 3:05 PM |
| Details | State | Insert | | | Pending | 7/5/2016 3:05 PM |
| Dates | Registration Date | Insert | | | 7/5/2016 12:00:00 AM | 7/5/2016 3:05 PM |
| Dates | Signed By Date | Insert | | | 7/5/2016 12:00:00 AM | 7/5/2016 3:05 PM |
| Dates | Start Date | Insert | | | | 7/5/2016 3:05 PM |
| Terminations | Termination Comments | Insert | | | | 7/5/2016 3:05 PM |
| Terminations | Termination Date | Insert | | | | 7/5/2016 3:05 PM |
| Terminations | Termination Effective Date | Insert | | | | 7/5/2016 3:05 PM |
| Terminations | Termination Reason | Insert | | | | 7/5/2016 3:05 PM |