Covered Entity Details

RRC330119-08 LENOX HILL HOSPITAL (Terminated) - information as of 4/29/2025 1:43:32 AM

Main Details

Name

LENOX HILL HOSPITAL

Subdivision Name

Manhattan Eye, Ear, & Throat Hospital - Eye Clinic

Type

Rural Referral Center

Rural

Yes

340B ID

RRC330119-08

Medicare Provider Number

330119

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

5/12/2017

Participating Start Date

7/1/2017

Participating Approval Date

6/8/2017

Last Recertification Date

8/24/2021

Termination Date
Termination Reason

1/24/2022
Change of hospital entity type

Contacts

Authorizing Official

Northwell Health
Michele L Cusack, Executive Vice President
(516) 321-6058

Primary Contact

Northwell
Onisis Stefas, VP of Pharmacy Operations
(516) 719-5720

Addresses

Street Address

210 E 64th St
New York, NY 10065

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
AR	233561105	1477616571
AZ	833823	1477616571
CA	1477616571	1477616571
CO	1457888398	1477616571
CT	003025475	1477616571
DC	044380100	1477616571
FL	906493100	1477616571
GA	003158071A	1477616571
IA	1477616571	1477616571
IL	131624070001	1477616571
IN	300032608	1477616571
KY	7100642240	1477616571
MA	110066805B	1477616571
MD	417411900	1477616571
ME	1477616571	1477616571
MI	1477616571	1477616571
MN	1477616571	1477616571
MO	1477616571	1477616571
NC	1477616571	1477616571
NH	20001744	1477616571
NJ	4153201	1477616571
OH	0640622	1477616571
OK	200108510A	1477616571
PA	1019871520001	1477616571
RI	1477616571	1477616571
SC	12105B	1477616571
TN	1526996	1477616571
VA	1477616571	1477616571
VT	1022131	1477616571
WI	1477616571	1477616571
NY	00243421	1477616571

Shipping Addresses

Shipping Address 1

Manhattan Eye, Ear, & Throat Hospital - Eye Clinic
210 E 64th St
New York, NY 10065

Shipping Address 2

Lenox Hill Hospital
100 EAST 77TH STREET
New York, NY 10075

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
RRC330119-01	Child	RRC	LENOX HILL HOSPITAL	Lenox Health Greenwich Village ER	30 7th Avenue	New York	NY	Terminated
RRC330119-02	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Mental Health Clinic	210 E 64th St	New York	NY	Terminated
RRC330119-03	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Plastic Surgery Clinic	210 E 64th St	New York	NY	Terminated
RRC330119-04	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Operating Room	210 E 64th St	New York	NY	Terminated
RRC330119-05	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Recovery Room	210 E 64th St	New York	NY	Terminated
RRC330119-06	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Radiology	210 E 64th St	New York	NY	Terminated
RRC330119-07	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Laser Center	210 E 64th St	New York	NY	Terminated
RRC330119-08	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, & Throat Hospital - Eye Clinic	210 E 64th St	New York	NY	Terminated
RRC330119-09	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, and Throat Hospital - Primary Care RDC	210 E 64th St	New York	NY	Terminated
RRC330119-10	Child	RRC	LENOX HILL HOSPITAL	Lenox Health Greenwich Village - Imaging - CT Scan	200 West 13th Street	New York	NY	Terminated
RRC330119-11	Child	RRC	LENOX HILL HOSPITAL	Lenox Health Greenwich Village - Imaging - MRI	200 West 13th Street	New York	NY	Terminated
RRC330119-12	Child	RRC	LENOX HILL HOSPITAL	Lenox Health Greenwich Village - Imaging - Ultrasound Diagnostic	200 West 13th Street	New York	NY	Terminated
RRC330119-13	Child	RRC	LENOX HILL HOSPITAL	Lenox Health Greenwich Village - Imaging - Radiology Diagnostic	200 West 13th Street	New York	NY	Terminated
RRC330119-14	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, and Throat Hospital - Ambulatory Infusion	210 E 64th St	New York	NY	Terminated
RRC330119-15	Child	RRC	LENOX HILL HOSPITAL	Manhattan Eye, Ear, and Throat Hospital - Laboratory	210 E 64th St	New York	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5163216058	Cusack, Michele L Executive Vice President Northwell Health 5163216058	9/6/2023 3:19 PM
Dates	Last Date That 340B Drugs Purchased	Update	OPA Edit Termination Info	4/1/2022 12:00:00 AM	1/24/2022 12:00:00 AM	2/16/2022 6:57 AM
Details	State	Update	OPA Edit Termination Info	To Be Terminated	Terminated	2/16/2022 6:57 AM
Terminations	Termination Date	Update	OPA Edit Termination Info	4/1/2022 12:00:00 AM	1/24/2022 12:00:00 AM	2/16/2022 6:57 AM
Terminations	Termination Effective Date	Update	OPA Edit Termination Info	4/1/2022 12:00:00 AM	1/24/2022 12:00:00 AM	2/16/2022 6:57 AM
Terminations	Termination Reason	Update	OPA Edit Termination Info	Change of covered entity type	Change of hospital entity type	2/16/2022 6:57 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	1/12/2022 11:49 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	1/12/2022 11:49 AM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	1/12/2022 11:49 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	1/12/2022 11:49 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	1/12/2022 11:49 AM
Details	Last Recertification Date	Update	Recertification	9/4/2020 10:10:13 AM	8/24/2021 10:34:32 AM	8/24/2021 10:34 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		233561105	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		833823	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1457888398	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003025475	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CT	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		044380100	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		DC	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		906493100	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003158071A	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		131624070001	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		300032608	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IN	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		7100642240	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110066805B	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		417411900	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MD	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		20001744	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NH	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4153201	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0640622	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		200108510A	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OK	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1019871520001	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		RI	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		12105B	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1526996	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VA	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1022131	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		VT	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		AR	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		CT	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		DC	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		GA	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		IA	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		IN	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		MA	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		MD	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		ME	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		MN	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		NH	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		OK	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		PA	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		RI	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		TN	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		VA	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		VT	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477616571	4/23/2021 11:06 AM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/23/2021 11:06 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1477616571	9/4/2020 10:10 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/4/2020 10:10 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1477616571 ( )		9/4/2020 10:10 AM
Details	Last Recertification Date	Update	Recertification	9/5/2019 12:19:04 PM	9/4/2020 10:10:13 AM	9/4/2020 10:10 AM
Addresses	Shipping Address	Insert	Change Request		Manhattan Eye, Ear, & Throat Hospital - Eye Clinic 210 E 64th St New York, NY 10065	3/13/2020 2:21 PM
Addresses	Shipping Address	Insert	Change Request		Lenox Hill Hospital 100 EAST 77TH STREET New York, NY 10075	3/13/2020 2:21 PM
Details	Last Recertification Date	Update	Recertification	9/5/2018 2:04:32 PM	9/5/2019 12:19:04 PM	9/5/2019 12:19 PM
Details	Last Recertification Date	Update	Recertification	12/1/2017 2:15:37 PM	9/5/2018 2:04:32 PM	9/5/2018 2:04 PM
Contacts	Authorizing Official	Update	Profile Change Request	Cusack, Michele L SVP & CFO Northwell Health 5168766061	Cusack, Michele L SVP & CFO Northwell Health 5163216058	1/19/2018 2:42 PM
Contacts	Authorizing Official	Update	AO Change Request	Shapiro, Robert S. EVP & CFO Northwell Health 5163216025	Cusack, Michele L SVP & CFO Northwell Health 5168766061	1/9/2018 2:25 PM
Details	Last Recertification Date	Update	Recertification		12/1/2017 2:15:37 PM	12/1/2017 2:15 PM
Contacts	Authorizing Official	Update		Shapiro, Robert EVP & CFO 5163216025	Shapiro, Robert S. EVP & CFO Northwell Health 5163216025	11/2/2017 12:09 PM
Contacts	Signed By	Update		Shapiro, Robert EVP & CFO 5163216025	Shapiro, Robert S. EVP & CFO Northwell Health 5163216025	11/2/2017 12:09 PM
Contacts	Primary Contact	Update		Stefas, Onisis VP of Pharmacy Operations 5167195720	Stefas, Onisis VP of Pharmacy Operations Northwell 5167195720	10/12/2017 1:11 PM
Contacts	Primary Contact	Insert			Stefas, Onisis VP of Pharmacy Operations 5167195720	7/25/2017 12:32 PM
Contacts	Authorizing Official	Insert			Shapiro, Robert EVP & CFO 5163216025	7/25/2017 7:35 AM
Contacts	Signed By	Insert			Shapiro, Robert EVP & CFO 5163216025	7/25/2017 7:35 AM
Addresses	Main Address	Insert			210 E 64th St New York, NY 10065	6/8/2017 2:27 PM
Dates	Participating Approval Date	Update			6/8/2017 12:00:00 AM	6/8/2017 2:25 PM
Details	State	Update		Pending	Active	6/8/2017 2:25 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	6/8/2017 2:25 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_77580	RRC330119-08	5/12/2017 11:19 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_77580	5/12/2017 10:22 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/12/2017 10:22 AM
Medicaid Billing	Medicaid: Number	Insert			00243421	5/12/2017 10:22 AM
Medicaid Billing	Medicaid: State	Insert			NY	5/12/2017 10:22 AM
Medicaid Billing	NPI: Number	Insert			1477616571	5/12/2017 10:22 AM
Details	Last Recertification Date	Insert				5/12/2017 10:22 AM
Details	Grant Number	Insert				5/12/2017 10:22 AM
Details	340B ID	Insert				5/12/2017 10:22 AM
Details	Is Authorizing Official EHB Data	Insert				5/12/2017 10:22 AM
Dates	Last Date That 340B Drugs Purchased	Insert				5/12/2017 10:22 AM
Details	Medicare Provider Number	Insert			330119	5/12/2017 10:22 AM
Details	Entity Name	Insert			LENOX HILL HOSPITAL	5/12/2017 10:22 AM
Details	Program Code	Insert			RRC	5/12/2017 10:22 AM
Details	Entity Subname	Insert			Manhattan Eye, Ear, & Throat Hospital - Eye Clinic	5/12/2017 10:22 AM
Dates	Participating Approval Date	Insert				5/12/2017 10:22 AM
Details	State	Insert			Pending	5/12/2017 10:22 AM
Dates	Registration Date	Insert			5/12/2017 12:00:00 AM	5/12/2017 10:22 AM
Dates	Signed By Date	Insert			5/12/2017 12:00:00 AM	5/12/2017 10:22 AM
Dates	Start Date	Insert				5/12/2017 10:22 AM
Terminations	Termination Comments	Insert				5/12/2017 10:22 AM
Terminations	Termination Date	Insert				5/12/2017 10:22 AM
Terminations	Termination Effective Date	Insert				5/12/2017 10:22 AM
Terminations	Termination Reason	Insert				5/12/2017 10:22 AM