Covered Entity Details

CH03310L Camden-On-Gauley Medical Center, Inc. (Active) - information as of 6/7/2025 4:46:13 AM

Main Details

Name

Camden-On-Gauley Medical Center, Inc.

Subdivision Name

Camden Family Health - Panther Creek

Type

HRSA-Funded Health Center

Site ID

BPS-H80-018495

340B ID

CH03310L

Grant Number

H80CS00078

Additional Details

Current Program Status

Active

Registration Date

4/5/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/18/2017

Last Recertification Date

2/23/2025

Contacts

Authorizing Official

Camden on Gauley Medical Center, Inc.
Margaret E Hickey, CEO
(304) 226-5725 Ext: 131

Primary Contact

Camden on Gauley Medical Center Inc.
Nathan Todd Angus, Director of Pharmacy
(304) 226-5725

Addresses

Street Address

110 Panther Creek Elementary School Rd.
Nettie, WV 26681

Billing Address

Camden on Gauley Medical Center, Inc
10003 Webster Road
Camden on Gauley, WV 26208

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
WV	1184147522,1386242600,1891236873,3810016790,1295179539,1801096000,2003133000,3810018441,1922468529,3810023145,3810029176,1134259278,3810028876,1003489808,1346599313,0049819000,1821507492,1932752078,1083015184,1952931842,3810026528,1245455914,1518451293,1972027894,1174389340,1871880856,1083829402,1952121055,3810016219,1134165251,3810024825,3910006375,0143072000,3810028090,1174065916	1417209784,1134521966,1801935242,1033519558,1174065916,1184147522,1386242600,1891236873,1730417700,1295179539,1316929227,1932163722,1568661064,1003089905,1922468529,1386900140,1003203316,1134259278,1295824365,1821507492,1932752078,1083015184,1629403563,1245455914,1518451293,1972027894,1174389340,1871880856,1083829402,1952121055,1134165251,1346599313,1003489808,1437540374,1952931842

Shipping Addresses

Shipping Address 1

Camden on Gauley Medical Center, Inc
10003 Webster Road
Camden on Gauley, WV 26208

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.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH033100	Active	BPS-H80-004845	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	CAMDEN-ON-GAULEY MEDICAL CENTER	10003 Webster Rd	Camden On Gauley	WV
CH03310A	Terminated	BPS-H80-000590	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	CENTERAL WV COMMUNITY HLTH CTR	55 Friends R Fun Dr	Summersville	WV
CH03310C	Active	BPS-H80-002948	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Webster County School Based Community Health Center	1 Highlander Dr	Upperglade	WV
CH03310E	Active	BPS-H80-012531	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Camden Family Health - Cowen Office	56 Park Street	Cowen	WV
CH03310F	Active	BPS-H80-012964	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Camden Family Health	100 School St	Craigsville	WV
CH03310G	Active	BPS-H80-017408	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Camden Family Health - Red Oak Drive	46 Red Oak Drive	Craigsville	WV
CH03310H	Active	BPS-H80-015330	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Camden Family Health	300 Minuteman Drive	Weston	WV
CH03310J	Terminated	BPS-H80-017492	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Camden Family Health - Richwood	58 East Main Street	Richwood	WV
CH03310K	Active	BPS-H80-019368	Camden-On-Gauley Medical Center, Inc.	Camden Family Health	71 Avenue A	Richwood	WV
CH03310L	Active	BPS-H80-018495	Camden-On-Gauley Medical Center, Inc.	Camden Family Health - Panther Creek	110 Panther Creek Elementary School Rd.	Nettie	WV
CH03310M	Active	BPS-H80-019575	Camden-On-Gauley Medical Center, Inc.	Camden Family Health - Cherry River	190 Riverside Drive, Room 2109	Richwood	WV
CH03310N	Active	BPS-H80-018928	Camden-On-Gauley Medical Center, Inc.	Camden Family Health	16414 Webster Road	Craigsville	WV
CH03310P	Active	BPS-H80-021528	Camden-On-Gauley Medical Center, Inc.	Camden Family Health	415 Main St	Summersville	WV
CH03310Q	Active	BPS-H80-024785	Camden-On-Gauley Medical Center, Inc.	Camden Family Health - Summersville Elementary School	70 Grade School Lane	Summersville	WV
CH03310R	Active	BPS-H80-031424	Camden-On-Gauley Medical Center, Inc.	Camden Family Health - Ansted	101 Florence St	Ansted	WV
CH03310S	Active	BPS-H80-032513	Camden-On-Gauley Medical Center, Inc.	Camden Family Health - Mobile	415 Main St	Summersville	WV
CH03310T	Active	BPS-H80-033020	Camden-On-Gauley Medical Center, Inc.	Camden Family Health Cherry River Mobile	190 Riverside Dr	Richwood	WV
CH03310U	Active	BPS-H80-035377	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Webster Springs Elementary School	318 River Drive BLDG	Webster Springs	WV
CH03310V	Active	BPS-H80-035299	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Hacker Valley Elementary School	11 School Loop Road	Hacker Valley	WV
CH03310W	Active	BPS-H80-035097	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Camden Family Vision Center	651 Water St	Summersville	WV
CH03310X	Active	BPS-H80-035797	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Kathleen & John Faltis Child Shelter	477 Scenic Highway	Summersville	WV
CH03310Y	Active	BPS-H80-033899	CAMDEN-ON-GAULEY MEDICAL CENTER, INC.	Camden Family Health - Richwood on Main	16 W Main St	Richwood	WV

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH033100	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	01/01/2024
CH033100	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	01/01/2024
CH033100	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2019
CH033100	GAULEY RIVER PHARMACY	GAULEY RIVER PHARMACY, INC.	433 CRAIGSVILLE RD. SUITE 2	CRAIGSVILLE	WV	26205	04/01/2019
CH033100	HIGHLANDER PHARMACY	HIGHLANDER PHARMACY	117 BACK FORK ST	WEBSTER SPRINGS	WV	26288-1032	04/01/2019
CH033100	MOUNTAIN LAKE PHARMACY	1129 BROAD ST	STE 100	SUMMERSVILLE	WV	26651	04/01/2019
CH033100	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2019	10/01/2022
CH033100	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2019
CH033100	WAL-MART PHARMACY 10-1477	200 WAL STREET		SUMMERSVILLE	WV	26651	04/01/2019
CH033100	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2019
CH033100	WALGREEN CO.	WALGREENS #17275	8 CHERRY RIVER PLZ	RICHWOOD	WV	26261-1371	04/01/2019	11/18/2021
CH033100	WALGREEN CO.	DBA: WALGREENS #11981	5870 WEBSTER RD.	SUMMERSVILLE	WV	26651	04/01/2019	11/06/2023
CH033100	WALGREEN CO.	WALGREENS #19990	18116 WEBSTER RD	CRAIGSVILLE	WV	26205	04/01/2019
CH033100	WALGREEN CO.	RITE AID #01687	306 N MAIN ST	WEBSTER SPRINGS	WV	26288	04/01/2019	02/18/2020
CH033100	WALGREEN CO.	RITE AID #01305	218 E 3RD ST.	WESTON	WV	26452	04/01/2019	02/18/2020
CH033100	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	01/01/2024
CH033100	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2019
CH033100	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2019
CH033100	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2019	10/01/2021
CH033100	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2019
CH033100	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CH033100	WALMART PHARMACY 10-6951	369 SCOTTS FORK-BONNIE RD		SUTTON	WV	26601	01/01/2020
CH033100	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024
CH033100	WEBSTER MEMORIAL HOSPITAL	PRESCRIPTION CENTER, COWEN	6815 WEBSTER RD	COWEN	WV	26206	10/01/2019
CH033100	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04167	700 NORTHSIDE DR.	SUMMERSVILLE	WV	26651	04/01/2019
CH033100	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05947	250 COURT STREET	WESTON	WV	26452	01/01/2025
CH033100	WEST VIRGINIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05946	72 WHITEWATER AVE.	FAYETTEVILLE	WV	25840	07/01/2025

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Recertification	7101036009 (WV)		2/23/2025 3:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	38100116219 (WV)		2/23/2025 3:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1114215779 (WV)		2/23/2025 3:30 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1285885814 (WV)		2/23/2025 3:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/23/2025 3:30 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3810016219	2/23/2025 3:30 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/23/2025 3:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/23/2025 3:30 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1134165251	2/23/2025 3:30 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/23/2025 3:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1134184211 (WV)		2/23/2025 3:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1114215779 (WV)		2/23/2025 3:30 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1285885814 (WV)		2/23/2025 3:30 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1134165251	2/23/2025 3:30 PM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/23/2025 3:30 PM
Details	Last Recertification Date	Update	Recertification	2/16/2024 3:33:27 PM	2/23/2025 3:30:06 PM	2/23/2025 3:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	12/16/2024 3:25 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1952121055	12/16/2024 3:25 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	12/16/2024 3:25 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1952121055	12/16/2024 3:25 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	12/16/2024 3:25 PM
Contacts	Primary Contact	Update	Group Change Request	Stark, Thomas Pharmacist Camden on Gauley Medical Center, Inc 3042265725	Angus, Nathan Todd Director of Pharmacy Camden on Gauley Medical Center Inc. 3042265725	11/26/2024 1:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/26/2024 9:49 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1083829402	7/26/2024 9:49 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	7/26/2024 9:49 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1083829402	7/26/2024 9:49 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	7/26/2024 9:49 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1972027894	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1174389340	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1871880856	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	4/7/2024 5:29 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1972027894	4/7/2024 5:29 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	4/7/2024 5:29 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1174389340	4/7/2024 5:29 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	4/7/2024 5:29 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1871880856	4/7/2024 5:29 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	4/7/2024 5:29 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1386053056 (WV)		3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1861049686 (WV)		3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1730612219 (WV)		3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1205183357 (WV)		3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1629403563 (WV)		3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3810026528	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1245455914	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1285885814	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1518451293	3/3/2024 12:51 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/3/2024 12:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1386053056 (WV)		3/3/2024 12:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1861049686 (WV)		3/3/2024 12:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1730612219 (WV)		3/3/2024 12:51 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1205183357 (WV)		3/3/2024 12:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1245455914	3/3/2024 12:51 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/3/2024 12:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1285885814	3/3/2024 12:51 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/3/2024 12:51 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1518451293	3/3/2024 12:51 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/3/2024 12:51 PM
Details	Last Recertification Date	Update	Recertification	2/21/2023 10:01:11 AM	2/16/2024 3:33:27 PM	2/16/2024 3:33 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	1/12/2024 3:15 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1952931842	1/12/2024 3:15 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	1/12/2024 3:15 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1952931842	1/12/2024 3:15 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	1/12/2024 3:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/31/2023 3:05 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1629403563	3/31/2023 3:05 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	3/31/2023 3:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1629403563	3/31/2023 3:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	3/31/2023 3:05 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1548867997 (WV)		2/21/2023 10:01 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	133133000 (WV)		2/21/2023 10:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/21/2023 10:01 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1932752078	2/21/2023 10:01 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/21/2023 10:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/21/2023 10:01 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1083015184	2/21/2023 10:01 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/21/2023 10:01 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1548867997 (WV)		2/21/2023 10:01 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1346353125 (WV)		2/21/2023 10:01 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932752078	2/21/2023 10:01 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/21/2023 10:01 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1083015184	2/21/2023 10:01 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/21/2023 10:01 AM
Details	Last Recertification Date	Update	Recertification	2/22/2022 9:36:19 AM	2/21/2023 10:01:11 AM	2/21/2023 10:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/29/2022 10:34 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1821507492	9/29/2022 10:34 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		WV	9/29/2022 10:34 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1821507492	9/29/2022 10:34 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		WV	9/29/2022 10:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/30/2022 6:07 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0049819000	6/30/2022 6:07 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	6/30/2022 6:07 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1295824365	6/30/2022 6:07 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	6/30/2022 6:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		3810028876	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1861049686	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		133133000	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1003489808	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1730612219	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1346599313	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1205183357	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1437540374	3/21/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1861049686	3/21/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346353125	3/21/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1003489808	3/21/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1730612219	3/21/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1346599313	3/21/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1205183357	3/21/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	3/21/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		7101036009	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1891236873	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3810016790	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1295179539	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1801096000	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2003133000	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3810018441	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		38100116219	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1922468529	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3810023145	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3810029176	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1114215779	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1134259278	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1134184211	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1891236873	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1730417700	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1295179539	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1316929227	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1932163722	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1568661064	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1003089905	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1922468529	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1386900140	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1003203316	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1114215779	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1134259278	2/22/2022 9:36 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	2/22/2022 9:36 AM
Details	Last Recertification Date	Update	Recertification	2/23/2021 9:43:08 AM	2/22/2022 9:36:19 AM	2/22/2022 9:36 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/12/2021 12:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1548867997	7/12/2021 12:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	7/12/2021 12:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1548867997	7/12/2021 12:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		WV	7/12/2021 12:30 PM
Details	Last Recertification Date	Update	Recertification	2/18/2020 6:43:52 AM	2/23/2021 9:43:08 AM	2/23/2021 9:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	11/7/2020 11:34 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1386242600	11/7/2020 11:34 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	11/7/2020 11:34 AM
Medicaid Billing	NPI: State	Update	Change Request		WV	11/7/2020 11:34 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1386242600	11/7/2020 11:34 AM
Medicaid Billing	NPI: State	Insert	Change Request		WV	11/7/2020 11:34 AM
Medicaid Billing	NPI: State	Update	Change Request		WV	11/7/2020 11:34 AM
Medicaid Billing	NPI: State	Update	Change Request		WV	11/7/2020 11:34 AM
Medicaid Billing	NPI: State	Update	Change Request		WV	11/7/2020 11:34 AM
Medicaid Billing	NPI: State	Update	Change Request		WV	11/7/2020 11:34 AM
Medicaid Billing	NPI: State	Update	Change Request		WV	11/7/2020 11:34 AM
Medicaid Billing	NPI: State	Update	Change Request		WV	11/7/2020 11:34 AM
Contacts	Primary Contact	Update	Recertification	Stark, Thomas Pharmacist Camden on Gauley Medical Center, Inc. 3048721663	Stark, Thomas Pharmacist Camden on Gauley Medical Center, Inc 3042265725	2/18/2020 6:43 AM
Details	Last Recertification Date	Update	Recertification	2/5/2019 9:44:01 AM	2/18/2020 6:43:52 AM	2/18/2020 6:43 AM
Contacts	Authorizing Official	Update	AO Change Request	Hickey, Margaret CEO Camden on Gauley Medical Center, Inc 3042265725	Hickey, Margaret E CEO Camden on Gauley Medical Center, Inc. 3042265725-131	1/30/2020 7:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/6/2020 3:04 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1386053056	1/6/2020 3:04 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		WV	1/6/2020 3:04 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1386053056	1/6/2020 3:04 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1992155832 (WV)		10/22/2019 9:20 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1992155832 ( )		10/22/2019 9:20 AM
Addresses	Billing Address	Insert	Recertification		Camden on Gauley Medical Center, Inc 10003 Webster Road Camden on Gauley, WV 26208	2/5/2019 9:44 AM
Addresses	Shipping Address	Insert	Recertification		Camden on Gauley Medical Center, Inc 10003 Webster Road Camden on Gauley, WV 26208	2/5/2019 9:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/5/2019 9:44 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1184147522	2/5/2019 9:44 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/5/2019 9:44 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1184147522	2/5/2019 9:44 AM
Details	Last Recertification Date	Update	Recertification	2/19/2018 4:15:42 PM	2/5/2019 9:44:01 AM	2/5/2019 9:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/19/2018 4:15 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1992155832	2/19/2018 4:15 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/19/2018 4:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/19/2018 4:15 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3810028090	2/19/2018 4:15 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/19/2018 4:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/19/2018 4:15 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1174065916	2/19/2018 4:15 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	2/19/2018 4:15 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1992155832	2/19/2018 4:15 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1033519558	2/19/2018 4:15 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1174065916	2/19/2018 4:15 PM
Details	Last Recertification Date	Update	Recertification		2/19/2018 4:15:42 PM	2/19/2018 4:15 PM
Details	Is Authorizing Official EHB Data	Update	Recertification	False		2/19/2018 4:15 PM
Contacts	Authorizing Official	Update	New Registration	Hickey, Margaret CEO 3042265725	Hickey, Margaret CEO Camden on Gauley Medical Center, Inc 3042265725	1/10/2018 6:47 PM
Contacts	Signed By	Update	New Registration	Hickey, Margaret CEO 3042265725	Hickey, Margaret CEO Camden on Gauley Medical Center, Inc 3042265725	1/10/2018 6:47 PM
Contacts	Primary Contact	Update		Stark, Thomas Pharmacist 3048721663	Stark, Thomas Pharmacist Camden on Gauley Medical Center, Inc. 3048721663	9/26/2017 4:32 PM
Contacts	Authorizing Official	Insert			Hickey, Margaret CEO 3042265725	7/13/2017 1:59 PM
Contacts	Signed By	Insert			Hickey, Margaret CEO 3042265725	7/13/2017 1:59 PM
Contacts	Primary Contact	Insert			Stark, Thomas Pharmacist 3048721663	7/13/2017 1:59 PM
Addresses	Main Address	Insert			110 Panther Creek Elementary School Rd. Nettie, WV 26681	5/1/2017 5:19 PM
Dates	Participating Approval Date	Update			4/18/2017 12:00:00 AM	4/18/2017 11:11 AM
Details	State	Update		Pending	Active	4/18/2017 11:11 AM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/18/2017 11:11 AM
Details	340B ID	Update		ONLINE_REG_76052	CH03310L	4/6/2017 2:35 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_76052	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: Number	Insert			3810024825	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: State	Insert			WV	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: Number	Insert			3910006375	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: State	Insert			WV	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: Number	Insert			0143072000	4/5/2017 4:52 PM
Medicaid Billing	Medicaid: State	Insert			WV	4/5/2017 4:52 PM
Medicaid Billing	NPI: Number	Insert			1417209784	4/5/2017 4:52 PM
Medicaid Billing	NPI: Number	Insert			1134521966	4/5/2017 4:52 PM
Medicaid Billing	NPI: Number	Insert			1801935242	4/5/2017 4:52 PM
Details	Last Recertification Date	Insert				4/5/2017 4:52 PM
Details	Grant Number	Insert			H80CS00078	4/5/2017 4:52 PM
Details	340B ID	Insert			ONLINE_REG	4/5/2017 4:52 PM
Details	Is Authorizing Official EHB Data	Insert			False	4/5/2017 4:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/5/2017 4:52 PM
Details	Medicare Provider Number	Insert				4/5/2017 4:52 PM
Details	Entity Name	Insert			Camden-On-Gauley Medical Center, Inc.	4/5/2017 4:52 PM
Details	Program Code	Insert			CH	4/5/2017 4:52 PM
Details	Entity Subname	Insert			Camden Family Health - Panther Creek	4/5/2017 4:52 PM
Dates	Participating Approval Date	Insert				4/5/2017 4:52 PM
Details	State	Insert			Pending	4/5/2017 4:52 PM
Dates	Registration Date	Insert			4/5/2017 12:00:00 AM	4/5/2017 4:52 PM
Dates	Signed By Date	Insert			4/5/2017 12:00:00 AM	4/5/2017 4:52 PM
Dates	Start Date	Insert				4/5/2017 4:52 PM
Terminations	Termination Comments	Insert				4/5/2017 4:52 PM
Terminations	Termination Date	Insert				4/5/2017 4:52 PM
Terminations	Termination Effective Date	Insert				4/5/2017 4:52 PM
Terminations	Termination Reason	Insert				4/5/2017 4:52 PM

340B Drug Pricing Program Database