Covered Entity Details

CHC08238-04 CHANGE, INCORPORATED (Active) - information as of 6/22/2025 12:04:49 AM

Main Details

Name

CHANGE, INCORPORATED

Subdivision Name

Family Medical Care Community Health Center - Newell

Type

HRSA-Funded Health Center

Site ID

BPS-H80-017702

340B ID

CHC08238-04

Grant Number

H80CS08238

Additional Details

Current Program Status

Active

Registration Date

10/3/2016

Participating Start Date

1/1/2017

Participating Approval Date

10/14/2016

Last Recertification Date

2/11/2025

Contacts

Authorizing Official

CHANGE, Inc.
Lisa Mowry, CEO
(304) 797-7733 Ext: 1311

Primary Contact

CHANGE, Inc.
James Boniey, Director of Program Operations
(304) 797-7733 Ext: 1309

Addresses

Street Address

1151 Washington St
Newell, WV 26050-2605

Billing Address

CHANGE, Inc.
3158 West St
Weirton, WV 26062-4637

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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
OH	2764236,2733993	1063918472,1174074686,1245244367,1528275971,1912311705,1952716433
WV	3810008955,3810025567,3910006477,3810007536	1528275971,1245244367,1912311705,1174074686,1063918472,1952716433

Shipping Addresses

Shipping Address 1

CHANGE, Inc.
3136 West Street
Weirton, WV 26062

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
Contract Detail	KROGER PHARMACY N-512	264 S HOLLYWOOD BLVD		STEUBENVILLE	OH	43952	04/18/2023	04/18/2023			04/18/2023

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC08238-00	Active	BPS-H80-000648	CHANGE, INCORPORATED	Family Medical Care Community Health Center - Hancock County	3136 West St	Weirton	WV
CHC08238-02	Active	BPS-H80-012164	CHANGE, INCORPORATED	Family Medical Care Community Health Center - Jefferson County	200 Luray Drive	Wintersville	OH
CHC08238-03	Active	BPS-H80-013884	CHANGE, INCORPORATED	FMC SBHC - Weirton Elementary	3428 Pennsylvania Ave	Weirton	WV
CHC08238-04	Active	BPS-H80-017702	CHANGE, INCORPORATED	Family Medical Care Community Health Center - Newell	1151 Washington St	Newell	WV
CHC08238-05	Active	BPS-H80-021757	Change, Incorporated	FMC -SBHC Brooke Complex	29 Bruin Drive	Wellsburg	WV
CHC08238-06	Active	BPS-H80-022073	Change, Incorporated	FMC - SBHC Toronto Complex	1305 DENNIS WAY	TORONTO	OH
CHC08238-07	Active	BPS-H80-022349	Change, Incorporated	FMC MAT	114 Taylor Ave	Weirton	WV
CHC08238-08	Active	BPS-H80-027259	Change, Incorporated	FMC - SBHC Weir Complex	100 Red Rider Rd	Weirton	WV
CHC08238-09	Active	BPS-H80-027370	Change, Incorporated	FMC - SBHC Oak Glen Complex	39 Golden Bear Dr	New Cumberland	WV
CHC08238-10	Active	BPS-H80-029429	Change, Incorporated	FMC - SBHC Garfield East Elementary School	936 N 5th St	Steubenville	OH
CHC08238-11	Active	BPS-H80-029428	Change, Incorporated	FMC - SBHC Harding Middle School	2002 Sunset Blvd	Steubenville	OH
CHC08238-12	Active	BPS-H80-029426	Change, Incorporated	FMC - SBHC McKinley STEM Academy	1400 Adams St	Steubenville	OH
CHC08238-13	Active	BPS-H80-029425	Change, Incorporated	FMC - SBHC Pugliese West Elementary School	435 John Scott Hwy	Steubenville	OH
CHC08238-14	Active	BPS-H80-038794	Change, Incorporated	FMC - SBHC Steubenville High School	320 North 4th Street, Room 151	Steubenville	OH
CHC08238-15	Active	BPS-H80-031058	Change, Incorporated	FMC SBHC Alternative Learning Center	1447 Main St	Wellsburg	WV
CHC08238-16	Active	BPS-H80-033012	Change, Incorporated	FMC SBHC Brooke Intermediate North	1098 Jefferson St	Follansbee	WV
CHC08238-17	Active	BPS-H80-033010	Change, Incorporated	FMC SBHC Brooke Intermediate South	1305 Washington Pike	Wellsburg	WV
CHC08238-18	Active	BPS-H80-033013	Change, Incorporated	FMC SBHC Brooke Primary South	1448 Main St	Wellsburg	WV
CHC08238-19	Active	BPS-H80-033011	Change, Incorporated	FMC SBHC Brooke Primary North	200 Rockdale Rd	Follansbee	WV
CHC08238-20	Active	BPS-H80-032123	Change, Incorporated	Mobile Van #1	1151 Washington St	Newell	WV
CHC08238-21	Active	BPS-H80-038170	CHANGE INC	FMC - SBHC Indian Creek High School	200 Park Dr	Wintersville	OH
CHC08238-22	Active	BPS-H80-037634	CHANGE INC	FMC - SBHC Indian Creek Middle School	2379 Wilson Ave	Mingo Junction	OH
CHC08238-23	ToBeTerminated	BPS-H80-038794	CHANGE INC	FMC - SBHC Steubenville High School	320 North 4th Street, Room 151	Steubenville	OH

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC08238-00	A & B SUNSET PHCY	4201-A SUNSET BLVD		STEUBENVILLE	OH	43952	07/01/2025
CHC08238-21	A & B SUNSET PHCY	4201-A SUNSET BLVD		STEUBENVILLE	OH	43952	07/01/2025
CHC08238-22	A & B SUNSET PHCY	4201-A SUNSET BLVD		STEUBENVILLE	OH	43952	07/01/2025
CHC08238-00	ACARIAHEALTH PHARMACY #11, INC	1311 W SAM HOUSTON PKWY N STE 130		HOUSTON	TX	77043-4015	01/01/2023	12/31/2024
CHC08238-00	ACARIAHEALTH PHARMACY #12, INC.	5 SKYLINE DR STE 240		HAWTHORNE	NY	10532-2166	01/01/2023	12/31/2024
CHC08238-00	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/01/2024
CHC08238-00	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/01/2024
CHC08238-00	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	10/01/2024
CHC08238-00	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/01/2024
CHC08238-00	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/01/2024
CHC08238-00	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	10/01/2024
CHC08238-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/01/2024
CHC08238-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/01/2024
CHC08238-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	04/01/2024
CHC08238-16	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/01/2024
CHC08238-17	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/01/2024
CHC08238-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	10/01/2024
CHC08238-00	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	10/01/2024
CHC08238-00	CITIZENS DRUG STR OF CHESTER	LOUCAS/KARNOUPAKIS ENT	501 CAROLINA AVE PO BOX 198	CHESTER	WV	26034	04/01/2013
CHC08238-15	CITIZENS DRUG STR OF CHESTER	LOUCAS/KARNOUPAKIS ENT	501 CAROLINA AVE PO BOX 198	CHESTER	WV	26034	04/01/2023
CHC08238-00	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	01/01/2023	10/14/2022
CHC08238-00	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018
CHC08238-00	DAVIS BROTHERS PHARMACY	LEGAL BUSINESS NAME: DAVIS BROTHERS PHA	615 N CHESTER ST	NEW CUMBERLAND	WV	26047	01/01/2016
CHC08238-14	DAVIS BROTHERS PHARMACY	LEGAL BUSINESS NAME: DAVIS BROTHERS PHA	615 N CHESTER ST	NEW CUMBERLAND	WV	26047	04/01/2023
CHC08238-00	DAVIS BROTHERS PHARMACY - CHESTER	559 CAROLINA AVE STE B		CHESTER	WV	26034	04/01/2017	07/01/2024
CHC08238-02	DAVIS BROTHERS PHARMACY - CHESTER	559 CAROLINA AVE STE B		CHESTER	WV	26034	04/18/2023	07/02/2024
CHC08238-00	DIAMOND PHARMACY	503 CADIZ RD		WINTERSVILLE	OH	43953-4126	07/01/2025
CHC08238-21	DIAMOND PHARMACY	503 CADIZ RD		WINTERSVILLE	OH	43953-4126	07/01/2025
CHC08238-22	DIAMOND PHARMACY	503 CADIZ RD		WINTERSVILLE	OH	43953-4126	07/01/2025
CHC08238-00	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	04/01/2024
CHC08238-00	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	10/01/2024
CHC08238-00	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	10/01/2024
CHC08238-00	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	10/01/2024
CHC08238-00	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	10/01/2024
CHC08238-00	FOLLANSBEE PHARMACY	1415 MAIN ST		FOLLANSBEE	WV	26037-1217	06/22/2012
CHC08238-13	FOLLANSBEE PHARMACY	1415 MAIN ST		FOLLANSBEE	WV	26037-1217	04/01/2023
CHC08238-00	FOUNDATION CARE LLC	111 CHESTERFIELD INDUSTRIAL BLVD STE 115		CHESTERFIELD	MO	63005	01/01/2023	12/31/2024
CHC08238-00	GIANT EAGLE PHARMACY #1475	15937 STATE RT 170		EAST LIVERPOOL	OH	43920	10/01/2017	10/01/2018
CHC08238-00	GIANT EAGLE PHARMACY #1479	619 BRADSHAW AVENUE		EAST LIVERPOOL	OH	43920	10/01/2017	10/01/2018
CHC08238-00	HERCHE BLOOR PHARMACY	104 E 5TH ST		EAST LIVERPOOL	OH	43920	01/01/2019
CHC08238-12	HERCHE BLOOR PHARMACY	104 E 5TH ST		EAST LIVERPOOL	OH	43920	04/01/2023
CHC08238-00	HOOD'S PHARMACY INC	JOSEPH A.IERISE	971 MAIN ST PO BOX 455	FOLLANSBEE	WV	26037-2603	10/01/2016
CHC08238-11	HOOD'S PHARMACY INC	JOSEPH A.IERISE	971 MAIN ST PO BOX 455	FOLLANSBEE	WV	26037-2603	04/01/2023
CHC08238-00	KROGER COLUMBUS CENTRAL FILL #019	2270 RICKENBACKER PKWY W		COLUMBUS	OH	43217	04/01/2017
CHC08238-00	KROGER PHARMACY	100 ST THOMAS DRIVE		WEIRTON	WV	26062	01/01/2014
CHC08238-10	KROGER PHARMACY	100 ST THOMAS DRIVE		WEIRTON	WV	26062	04/18/2023
CHC08238-00	KROGER PHARMACY #268	91-27TH STREET		WELLSBURG	WV	26070	01/01/2022
CHC08238-00	KROGER PHARMACY #512	13201 RITTENHOUSE DRIVE		MIDLOTHIAN	VA	23112	01/01/2022	07/13/2022
CHC08238-00	KROGER PHARMACY N-215	3558 MAIN STREET		WEIRTON	WV	26062	01/01/2014	08/20/2020
CHC08238-00	KROGER PHARMACY N-512	264 S HOLLYWOOD BLVD		STEUBENVILLE	OH	43952	10/01/2022
CHC08238-04	KROGER PHARMACY N-512	264 S HOLLYWOOD BLVD		STEUBENVILLE	OH	43952	04/18/2023
CHC08238-00	KROGER SAV-ON PHARMACY N-963	858 MAIN STREET		WINTERSVILLE	OH	43953	10/01/2014
CHC08238-10	KROGER SAV-ON PHARMACY N-963	858 MAIN STREET		WINTERSVILLE	OH	43953	04/01/2023
CHC08238-00	NEW CUMBERLAND PRESCRIPTION	107 LINCOLN ST		NEW CUMBERLAND	WV	26047-9553	04/01/2013	11/01/2024
CHC08238-09	NEW CUMBERLAND PRESCRIPTION	107 LINCOLN ST		NEW CUMBERLAND	WV	26047-9553	04/01/2023	11/01/2024
CHC08238-00	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	07/01/2020	08/31/2020
CHC08238-00	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2020
CHC08238-00	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/01/2020	09/01/2021
CHC08238-00	PENN WAY PHARMACY	PENN WAY PHARMACY	3159 MAIN ST	WEIRTON	WV	26062	04/01/2017	01/08/2018
CHC08238-00	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2018
CHC08238-00	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	04/01/2024
CHC08238-00	RITE AID OF OHIO, INC.	RITE AID #450	138 NORTH 5TH STREET	STEUBENVILLE	OH	43952	01/01/2014	02/09/2018
CHC08238-00	RITE AID OF OHIO, INC.	RITE AID #875	4402 SUNSET BOULEVARD	STEUBENVILLE	OH	43952	01/01/2014	02/09/2018
CHC08238-00	RITE AID OF OHIO, INC.	RITE AID #2565	1820 FRANKLIN STREET	TORONTO	OH	43964	01/01/2014	02/09/2018
CHC08238-00	RITE AID OF WEST VIRGINIA, INC.	RITE AID #1949	1600 MAIN STREET	FOLLANSBEE	WV	26037	01/01/2014	02/09/2018
CHC08238-00	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	04/01/2024
CHC08238-00	ROSS PARK PHARMACY	1 ROSS PARK BLVD		STEUBENVILLE	OH	43952-2681	10/01/2014	09/14/2015
CHC08238-00	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	04/01/2024
CHC08238-00	THREE SPRINGS VILLAGE PHARMACY LLC	DBA VILLAGE PHARMACY	204 THREE SPRINGS DR SUITE A	WEIRTON	WV	26062	07/01/2020
CHC08238-00	THRIFT DRUG, INC.	RITE AID #11308	1360 COVE ROAD	WEIRTON	WV	26062	01/01/2014	02/09/2018
CHC08238-00	TRI-STATE PHARMACY	651 COLLIERS WAY STE 204	JOHN J. BERNABEI, RPH	WEIRTON	WV	26062-5055	01/01/2014
CHC08238-08	TRI-STATE PHARMACY	651 COLLIERS WAY STE 204	JOHN J. BERNABEI, RPH	WEIRTON	WV	26062-5055	04/01/2023
CHC08238-00	VALUE LEADER PHARMACY	DBA VALUE LEADER PHARMACY	201 LURAY DR STE B	WINTERSVILLE	OH	43953	10/01/2013
CHC08238-07	VALUE LEADER PHARMACY	DBA VALUE LEADER PHARMACY	201 LURAY DR STE B	WINTERSVILLE	OH	43953	04/01/2023
CHC08238-11	VALUE LEADER PHARMACY	DBA VALUE LEADER PHARMACY	201 LURAY DR STE B	WINTERSVILLE	OH	43953	04/18/2023
CHC08238-00	VILLAGE LONG TERM PHARMACY LLC	VILLAGE LONG TERM CARE PHARMACY	204 THREE SPRINGS DR SUITE B	WEIRTON	WV	26062	07/01/2025
CHC08238-22	VILLAGE LONG TERM PHARMACY LLC	VILLAGE LONG TERM CARE PHARMACY	204 THREE SPRINGS DR SUITE B	WEIRTON	WV	26062	07/01/2025
CHC08238-21	VILLAGE LONG TERM PHARMACY LLC	VILLAGE LONG TERM CARE PHARMACY	204 THREE SPRINGS DR SUITE B	WEIRTON	WV	26062	07/01/2025
CHC08238-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2019
CHC08238-00	WAL-MART PHARMACY 10-1707	16280 DRESDEN DR		EAST LIVERPOOL	OH	43920	01/01/2019
CHC08238-09	WAL-MART PHARMACY 10-1707	16280 DRESDEN DR		EAST LIVERPOOL	OH	43920	04/18/2023
CHC08238-00	WAL-MART PHARMACY 10-1948	400 THREE SPRINGS DR		WEIRTON	WV	26062	01/01/2019
CHC08238-05	WAL-MART PHARMACY 10-1948	400 THREE SPRINGS DR		WEIRTON	WV	26062	04/18/2023
CHC08238-00	WAL-MART PHARMACY 10-2193	100 MALL DRIVE		STEUBENVILLE	OH	43952	01/01/2019
CHC08238-03	WAL-MART PHARMACY 10-2193	100 MALL DRIVE		STEUBENVILLE	OH	43952	04/18/2023
CHC08238-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2019
CHC08238-00	WALGREEN CO.	DBA: WALGREENS #11695	2001 SUNSET BLVD.	STEUBENVILLE	OH	43952	04/01/2015	04/15/2016
CHC08238-00	WALGREEN CO.	WALGREENS #19676	1360 COVE RD	WEIRTON	WV	26062-4205	02/27/2018
CHC08238-00	WALGREEN CO.	WALGREENS #19743	1600 MAIN ST	FOLLANSBEE	WV	26037	02/27/2018
CHC08238-00	WALGREEN CO.	RITE AID #00450	138 N 5TH ST	STEUBENVILLE	OH	43952	02/28/2018	08/23/2018
CHC08238-00	WALGREEN CO.	WALGREEN #19910	1820 FRANKLIN ST	TORONTO	OH	43964	02/28/2018
CHC08238-00	WALGREEN CO.	WALGREENS #17303	4402 SUNSET BLVD	STEUBENVILLE	OH	43952	02/28/2018
CHC08238-00	WALGREEN CO.	DBA: WALGREENS #11695	2001 SUNSET BLVD.	STEUBENVILLE	OH	43952	01/01/2019	11/08/2023
CHC08238-00	WALGREEN CO.	WALGREENS #19991	126 12TH ST.	WELLSBURG	WV	26070-1572	07/01/2019
CHC08238-00	WALGREEN CO.	WALGREENS #18289	400 PUBLIC RD	YORKVILLE	OH	43971	01/01/2022	04/24/2025
CHC08238-06	WALGREEN CO.	WALGREENS #19743	1600 MAIN ST	FOLLANSBEE	WV	26037	04/18/2023
CHC08238-07	WALGREEN CO.	WALGREENS #19991	126 12TH ST.	WELLSBURG	WV	26070-1572	04/18/2023
CHC08238-08	WALGREEN CO.	DBA: WALGREENS #11695	2001 SUNSET BLVD.	STEUBENVILLE	OH	43952	04/18/2023
CHC08238-00	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	01/01/2024
CHC08238-00	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/01/2015	07/06/2015
CHC08238-00	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	04/01/2015	07/06/2015
CHC08238-00	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2018
CHC08238-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2018
CHC08238-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2018
CHC08238-00	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2018
CHC08238-00	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CHC08238-00	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	1/29/2024 8:08:23 AM	2/11/2025 11:16:52 AM	2/11/2025 11:16 AM
Details	Last Recertification Date	Update	Recertification	1/31/2023 8:00:05 AM	1/29/2024 8:08:23 AM	1/29/2024 8:08 AM
Details	Last Recertification Date	Update	Recertification	2/9/2022 1:31:46 PM	1/31/2023 8:00:05 AM	1/31/2023 8:00 AM
Addresses	Shipping Address	Insert	Group Change Request		CHANGE, Inc. 3136 West Street Weirton, WV 26062	2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1598249393 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1013565571 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1154893840 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1932677507 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1013565571 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1043546443 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053365262 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1083124036 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1104949338 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1154893840 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1235680372 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1265416929 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1346537321 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1346587409 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1437551918 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457722555 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457727281 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457847667 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1497208847 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1548608896 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1568438539 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1588069561 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1588652499 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1598249393 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1629196571 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1639169923 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1689671703 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1730176900 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1740624337 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1831281856 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1891129441 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1891781084 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1902875743 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1912259920 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1932677507 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1942592035 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1942725684 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457722555 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1891129441 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1629366463 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1548860471 (OH)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1629366463 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1548860471 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1902875743 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1891781084 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1053365262 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1689671703 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1588652499 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1568438539 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1043546443 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1548608896 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1942592035 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1346587409 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1912259920 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1437551918 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457727281 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1740624337 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1831281856 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1730176900 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1235680372 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1265416929 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1942725684 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1588069561 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1104949338 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1639169923 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1497208847 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1629196571 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457847667 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1346537321 (WV)		2/28/2022 9:18 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1083124036 (WV)		2/28/2022 9:18 AM
Details	Last Recertification Date	Update	Recertification	2/4/2021 9:24:10 AM	2/9/2022 1:31:46 PM	2/9/2022 1:31 PM
Contacts	Authorizing Official	Update	AO Change Request	Raveaux, Judy CEO CHANGE, Incorporated 3047977733-1311	Mowry, Lisa CEO CHANGE, Inc. 3047977733-1311	2/7/2022 8:44 AM
Details	Last Recertification Date	Update	Recertification	1/28/2020 7:58:44 AM	2/4/2021 9:24:10 AM	2/4/2021 9:24 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1629366463	1/6/2021 11:02 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	1/6/2021 11:02 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1548860471	1/6/2021 11:02 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	1/6/2021 11:02 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1629366463	1/6/2021 11:02 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	1/6/2021 11:02 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1548860471	1/6/2021 11:02 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	1/6/2021 11:02 AM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1013565571	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1043546443	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053365262	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1063918472	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083124036	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1104949338	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1154893840	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174074686	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1235680372	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1245244367	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265416929	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346537321	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1346587409	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1437551918	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1457722555	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1457727281	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1457847667	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1497208847	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1528275971	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1548608896	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1568438539	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1588069561	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1588652499	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1598249393	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1629196571	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639169923	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1689671703	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1730176900	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1740624337	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1831281856	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1891129441	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1891781084	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1902875743	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1912259920	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1912311705	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1932677507	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1942592035	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1942725684	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952716433	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		OH	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1457722555	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1891129441	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: State	Update	Change Request		WV	10/15/2020 1:56 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1285642793 ( )		7/9/2020 6:39 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1154893840	4/3/2020 11:18 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1932677507	4/3/2020 11:18 AM
Details	Last Recertification Date	Update	Recertification	1/29/2019 6:34:12 AM	1/28/2020 7:58:44 AM	1/28/2020 7:58 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1598249393	1/14/2020 7:09 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1013565571	1/14/2020 7:09 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1770095168 ( )		10/1/2019 12:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1770095168	10/1/2019 9:31 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1922004589 ( )		10/1/2019 9:31 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1528399458 ( )		7/9/2019 1:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1194240937 ( )		7/9/2019 1:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1174534291 ( )		7/9/2019 1:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1568426419 ( )		7/9/2019 1:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1932282738 ( )		7/9/2019 1:30 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1770095168 ( )		7/9/2019 1:30 PM
Details	Last Recertification Date	Update	Recertification	2/7/2018 12:22:01 PM	1/29/2019 6:34:12 AM	1/29/2019 6:34 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1932282738	1/10/2019 1:06 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1770095168	1/10/2019 1:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1427111848 ( )		10/2/2018 12:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1063918472	10/2/2018 12:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083124036	10/2/2018 12:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1952716433	10/2/2018 12:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1457847667	8/2/2018 8:22 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346537321	8/2/2018 8:22 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1699771527 ( )		4/4/2018 9:49 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1780082693 ( )		4/4/2018 9:49 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1841642105 ( )		4/4/2018 9:49 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1568426419	4/4/2018 9:49 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1629196571	4/4/2018 9:49 AM
Contacts	Primary Contact	Update	Change Request	McKenna, John Pharmacy Director change inc 3047484200-1103	Boniey, James Director of Program Operations CHANGE, Inc. 3047977733-1309	4/4/2018 9:49 AM
Details	Last Recertification Date	Update	Recertification	2/7/2017 12:00:00 AM	2/7/2018 12:22:01 PM	2/7/2018 12:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1487781134 ( )		1/31/2018 9:07 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/9/2018 1:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3810007536	1/9/2018 1:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	1/9/2018 1:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/9/2018 1:13 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2733993	1/9/2018 1:13 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	1/9/2018 1:13 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841262656 ( )		1/9/2018 1:13 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1740590140 ( )		1/9/2018 1:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1639169923	1/9/2018 1:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1497208847	1/9/2018 1:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1194240937	10/19/2017 3:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1942725684	10/19/2017 3:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174534291	10/19/2017 3:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1588069561	10/19/2017 3:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1104949338	10/19/2017 3:51 PM
Details	Is Authorizing Official EHB Data	Update	Change Request	False		10/19/2017 3:51 PM
Contacts	Authorizing Official	Update		Raveaux, Judy CEO 3047977733-1311	Raveaux, Judy CEO CHANGE, Incorporated 3047977733-1311	9/29/2017 12:40 PM
Contacts	Signed By	Update		Raveaux, Judy CEO 3047977733-1311	Raveaux, Judy CEO CHANGE, Incorporated 3047977733-1311	9/29/2017 12:40 PM
Contacts	Primary Contact	Update		McKenna, John Pharmacy Director 3047484200-1103	McKenna, John Pharmacy Director change inc 3047484200-1103	9/29/2017 11:36 AM
Addresses	Main Address	Insert			1151 Washington St Newell, WV 26050-2605	8/2/2017 3:09 PM
Addresses	Billing Address	Insert			CHANGE, Inc. 3158 West St Weirton, WV 26062-4637	8/2/2017 3:09 PM
Contacts	Primary Contact	Insert			McKenna, John Pharmacy Director 3047484200-1103	8/2/2017 3:09 PM
Contacts	Authorizing Official	Insert			Raveaux, Judy CEO 3047977733-1311	8/2/2017 3:09 PM
Contacts	Signed By	Insert			Raveaux, Judy CEO 3047977733-1311	8/2/2017 3:09 PM
Medicaid Billing	NPI: Number	Insert			1235680372	8/2/2017 3:09 PM
Medicaid Billing	NPI: Number	Insert			1285642793	8/2/2017 3:09 PM
Medicaid Billing	NPI: Number	Insert			1265416929	8/2/2017 3:09 PM
Medicaid Billing	NPI: Number	Insert			1174074686	8/2/2017 3:09 PM
Details	Last Recertification Date	Update			2/7/2017 12:00:00 AM	2/7/2017 12:18 PM
Medicaid Billing	Medicaid: State	Update		OH	WV	1/24/2017 8:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/12/2017 7:19 AM
Medicaid Billing	Medicaid: Number	Insert			3810025567	1/12/2017 7:19 AM
Medicaid Billing	Medicaid: State	Insert			OH	1/12/2017 7:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/12/2017 7:19 AM
Medicaid Billing	Medicaid: Number	Insert			3910006477	1/12/2017 7:19 AM
Medicaid Billing	Medicaid: State	Insert			WV	1/12/2017 7:19 AM
Medicaid Billing	NPI: Number	Insert			1730176900	1/12/2017 7:19 AM
Medicaid Billing	NPI: Number	Insert			1841642105	1/12/2017 7:19 AM
Dates	Participating Approval Date	Update			10/14/2016 12:00:00 AM	10/14/2016 5:39 PM
Details	State	Update		Pending	Active	10/14/2016 5:39 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	10/14/2016 5:39 PM
Details	340B ID	Update		ONLINE_REG_72241	CHC08238-04	10/6/2016 10:09 AM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_72241	10/3/2016 12:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/3/2016 12:51 PM
Medicaid Billing	Medicaid: Number	Insert			2764236	10/3/2016 12:51 PM
Medicaid Billing	Medicaid: State	Insert			OH	10/3/2016 12:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/3/2016 12:51 PM
Medicaid Billing	Medicaid: Number	Insert			3810008955	10/3/2016 12:51 PM
Medicaid Billing	Medicaid: State	Insert			WV	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1528275971	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1245244367	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1902875743	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1891781084	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1841262656	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1053365262	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1689671703	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1588652499	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1568438539	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1922004589	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1740590140	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1043546443	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1528399458	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1548608896	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1942592035	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1346587409	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1427111848	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1912259920	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1912311705	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1437551918	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1457727281	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1740624337	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1699771527	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1831281856	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1780082693	10/3/2016 12:51 PM
Medicaid Billing	NPI: Number	Insert			1487781134	10/3/2016 12:51 PM
Details	Last Recertification Date	Insert				10/3/2016 12:51 PM
Details	Grant Number	Insert			H80CS08238	10/3/2016 12:51 PM
Details	340B ID	Insert			ONLINE_REG	10/3/2016 12:51 PM
Details	Is Authorizing Official EHB Data	Insert			False	10/3/2016 12:51 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/3/2016 12:51 PM
Details	Medicare Provider Number	Insert				10/3/2016 12:51 PM
Details	Entity Name	Insert			CHANGE, INCORPORATED	10/3/2016 12:51 PM
Details	Program Code	Insert			CH	10/3/2016 12:51 PM
Details	Entity Subname	Insert			Family Medical Care Community Health Center - Newell	10/3/2016 12:51 PM
Dates	Participating Approval Date	Insert				10/3/2016 12:51 PM
Details	State	Insert			Pending	10/3/2016 12:51 PM
Dates	Registration Date	Insert			10/3/2016 12:00:00 AM	10/3/2016 12:51 PM
Dates	Signed By Date	Insert			10/3/2016 12:00:00 AM	10/3/2016 12:51 PM
Dates	Start Date	Insert				10/3/2016 12:51 PM
Terminations	Termination Comments	Insert				10/3/2016 12:51 PM
Terminations	Termination Date	Insert				10/3/2016 12:51 PM
Terminations	Termination Effective Date	Insert				10/3/2016 12:51 PM
Terminations	Termination Reason	Insert				10/3/2016 12:51 PM

340B Drug Pricing Program Database