Covered Entity Details

DSH110226A DEKALB MEDICAL CENTER AT HILLANDALE - DBA EMORY HILLANDALE HOSPITAL (Active) - information as of 4/25/2025 9:21:35 PM

Main Details

Name

DEKALB MEDICAL CENTER AT HILLANDALE - DBA EMORY HILLANDALE HOSPITAL

Subdivision Name

DeKalb Hillandale Radiation Oncology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH110226A

Medicare Provider Number

110226

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/13/2016

Participating Start Date

1/1/2017

Participating Approval Date

11/15/2016

Last Recertification Date

8/23/2024

Contacts

Authorizing Official

Emory Decatur, Emory Hillandale
Lisa Urbistondo, Vice President & CFO
(404) 501-5025

Primary Contact

Emory Healthcare
Sydney Kchao, Corporate Director of Pharmacy, Business Operations and Finance
(404) 686-2147

Addresses

Street Address

2745 DeKalb Medical Parkway
Lithonia, GA 30058

Billing Address
Same as Street Address

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
GA	000000536U	1962403865

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
DSH110226A	Child	DSH	DEKALB MEDICAL CENTER AT HILLANDALE - DBA EMORY HILLANDALE HOSPITAL	DeKalb Hillandale Radiation Oncology	2745 DeKalb Medical Parkway	Lithonia	GA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 11:04:17 AM	8/23/2024 9:28:25 AM	8/23/2024 9:28 AM
Contacts	Primary Contact	Update	Change Request	Lastrapes, Marcia P 340B Program Manager Emory Healthcare 8633990008	Kchao, Sydney Corporate Director of Pharmacy, Business Operations and Finance Emory Healthcare 4046862147	5/21/2024 9:25 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 9:39:11 AM	9/6/2023 11:04:17 AM	9/6/2023 11:04 AM
Details	Last Recertification Date	Update	Recertification	8/16/2021 9:26:04 AM	8/25/2022 9:39:11 AM	8/25/2022 9:39 AM
Contacts	Authorizing Official	Update	Change Request	Daunt-Samford, Liz CFO DeKalb Medical 4045015025	Urbistondo, Lisa Vice President & CFO Emory Decatur, Emory Hillandale 4045015025	7/14/2022 6:57 AM
Details	Last Recertification Date	Update	Recertification	9/16/2020 10:54:53 AM	8/16/2021 9:26:04 AM	8/16/2021 9:26 AM
Contacts	Primary Contact	Update	Change Request	Mindel, Kristina Pharmacy Manager Emory Decatur Hospital 4045015044	Lastrapes, Marcia P 340B Program Manager Emory Healthcare 8633990008	7/9/2021 12:45 PM
Medicaid Billing	NPI: State	Update	Recertification		GA	9/16/2020 10:54 AM
Contacts	Primary Contact	Update	Recertification	Mindel, Kristina Pharmacy Manager DeKalb Medical 4045015044	Mindel, Kristina Pharmacy Manager Emory Decatur Hospital 4045015044	9/16/2020 10:54 AM
Details	Last Recertification Date	Update	Recertification	9/9/2019 10:47:43 AM	9/16/2020 10:54:53 AM	9/16/2020 10:54 AM
Details	Last Recertification Date	Update	Recertification	9/5/2018 11:18:16 AM	9/9/2019 10:47:43 AM	9/9/2019 10:47 AM
Details	Entity Name	Update	Change Request	DEKALB MEDICAL CENTER AT HILLANDALE	DEKALB MEDICAL CENTER AT HILLANDALE - DBA EMORY HILLANDALE HOSPITAL	11/16/2018 9:12 AM
Details	Last Recertification Date	Update	Recertification	12/5/2017 11:17:08 AM	9/5/2018 11:18:16 AM	9/5/2018 11:18 AM
Contacts	Authorizing Official	Update	AO Change Request	Wilson, Bob President and Chief Executive Officer DeKalb Medical 4045015209	Daunt-Samford, Liz CFO DeKalb Medical 4045015025	8/30/2018 12:02 PM
Details	Entity Name	Update	Recertification	DEKALB MEDICAL CENTER HILLANDALE	DEKALB MEDICAL CENTER AT HILLANDALE	12/5/2017 11:19 AM
Contacts	Authorizing Official	Update	Profile Change Request	Wilson, Bob Interim President and Chief Executive Officer DeKalb Medical 4045015209	Wilson, Bob President and Chief Executive Officer DeKalb Medical 4045015209	12/5/2017 11:18 AM
Contacts	Primary Contact	Update	Recertification	Kelvas, Martin System Pharmacy Director 4045015561	Mindel, Kristina Pharmacy Manager DeKalb Medical 4045015044	12/5/2017 11:17 AM
Details	Last Recertification Date	Update	Recertification		12/5/2017 11:17:08 AM	12/5/2017 11:17 AM
Contacts	Authorizing Official	Update		Wilson, Bob Interim President and Chief Executive Officer 4045015209	Wilson, Bob Interim President and Chief Executive Officer DeKalb Medical 4045015209	12/5/2017 11:08 AM
Contacts	Authorizing Official	Update		SHELTON, JOHN President and Chief Executive Officer 4045015209	Wilson, Bob Interim President and Chief Executive Officer 4045015209	9/11/2017 3:29 PM
Addresses	Main Address	Insert			2745 DeKalb Medical Parkway Lithonia, GA 30058	11/15/2016 4:32 PM
Contacts	Authorizing Official	Insert			SHELTON, JOHN President and Chief Executive Officer 4045015209	11/15/2016 4:32 PM
Contacts	Signed By	Insert			SHELTON, JOHN President and Chief Executive Officer 4045015209	11/15/2016 4:32 PM
Contacts	Primary Contact	Insert			Kelvas, Martin System Pharmacy Director 4045015561	11/15/2016 4:32 PM
Dates	Participating Approval Date	Update			11/15/2016 12:00:00 AM	11/15/2016 4:32 PM
Details	State	Update		Pending	Active	11/15/2016 4:32 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	11/15/2016 4:32 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_73050	DSH110226A	11/15/2016 12:42 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_73050	10/13/2016 12:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/13/2016 12:10 PM
Medicaid Billing	Medicaid: Number	Insert			000000536U	10/13/2016 12:10 PM
Medicaid Billing	Medicaid: State	Insert			GA	10/13/2016 12:10 PM
Medicaid Billing	NPI: Number	Insert			1962403865	10/13/2016 12:10 PM
Details	Last Recertification Date	Insert				10/13/2016 12:10 PM
Details	Grant Number	Insert				10/13/2016 12:10 PM
Details	340B ID	Insert				10/13/2016 12:10 PM
Details	Is Authorizing Official EHB Data	Insert				10/13/2016 12:10 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/13/2016 12:10 PM
Details	Medicare Provider Number	Insert			110226	10/13/2016 12:10 PM
Details	Entity Name	Insert			DEKALB MEDICAL CENTER HILLANDALE	10/13/2016 12:10 PM
Details	Program Code	Insert			DSH	10/13/2016 12:10 PM
Details	Entity Subname	Insert			DeKalb Hillandale Radiation Oncology	10/13/2016 12:10 PM
Dates	Participating Approval Date	Insert				10/13/2016 12:10 PM
Details	State	Insert			Pending	10/13/2016 12:10 PM
Dates	Registration Date	Insert			10/13/2016 12:00:00 AM	10/13/2016 12:10 PM
Dates	Signed By Date	Insert			10/13/2016 12:00:00 AM	10/13/2016 12:10 PM
Dates	Start Date	Insert				10/13/2016 12:10 PM
Terminations	Termination Comments	Insert				10/13/2016 12:10 PM
Terminations	Termination Date	Insert				10/13/2016 12:10 PM
Terminations	Termination Effective Date	Insert				10/13/2016 12:10 PM
Terminations	Termination Reason	Insert				10/13/2016 12:10 PM