Covered Entity Details

DSH060010D POUDRE VALLEY HOSPITAL (Active) - information as of 5/24/2025 12:46:31 AM

Main Details

Name

POUDRE VALLEY HOSPITAL

Subdivision Name

Heart Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH060010D

Medicare Provider Number

060010

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

3/9/2022

Participating Start Date

4/1/2022

Participating Approval Date

3/10/2022

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Poudre Valley Health Care, Inc.
David Charles Thompson, Chief Financial Officer
(970) 237-7011

Primary Contact

Poudre Valley Health Care, Inc.
Andrew Harmon, Director of Pharmacy
(970) 495-8054

Addresses

Street Address

2121 E Harmony Road
Suite 200
Fort Collins, CO 80528-3401

Billing Address

Poudre Valley Health Care Inc
2315 E Harmony Road
200
Fort Collins, CO 80528-8620

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participated starting on 7/1/2017; Terminated on 1/1/2018; Reinstated on 4/1/2022.	03/10/2022

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
CO	9000178613	1558920561,1760492714

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
DSH060010A	Child	DSH	POUDRE VALLEY HOSPITAL	UC Health - PVH Cancer Care and Hematology Center, Fort Collins	2121 E HARMONY RD	FORT COLLINS	CO	Active
DSH060010B	Child	DSH	POUDRE VALLEY HOSPITAL	UC Health - PVH Cancer Care and Hematology Center, Loveland	2500 Rocky Mountain Ave	Loveland	CO	Terminated
DSH060010C	Child	DSH	POUDRE VALLEY HOSPITAL	Harmony Emergency Department Pharmacy	B125	Fort Collins	CO	Terminated
DSH060010D	Child	DSH	POUDRE VALLEY HOSPITAL	Heart Center	2121 E Harmony Road	Fort Collins	CO	Active
DSH060010E	Child	DSH	POUDRE VALLEY HOSPITAL	Breast Diagnostic Center	2127 East Harmony Road	Fort Collins	CO	Active
DSH060010F	Child	DSH	POUDRE VALLEY HOSPITAL	Windsor Imaging	1455 Main St	Windsor	CO	Terminated
DSH060010G	Child	DSH	POUDRE VALLEY HOSPITAL	UC Health - PVH Cancer Care and Hematology Center, Greeley	1675 18th Avenue	Greeley	CO	Terminated
DSH060010L	Child	DSH	POUDRE VALLEY HOSPITAL	PVH MC-Adult CD&PHP - Mountain Crest	4601 Corbett Drive	Fort Collins	CO	Terminated
DSH060010M	Child	DSH	POUDRE VALLEY HOSPITAL	PVH Radiation Oncol - Rad Onc	2121 E. Harmony Road	Fort Collins	CO	Active
DSH060010N	Child	DSH	POUDRE VALLEY HOSPITAL	PVH Harmony ED - Emergency	4630 Snow Mesa Drive	Fort Collins	CO	Active
DSH060010P	Child	DSH	POUDRE VALLEY HOSPITAL	PVH Rehab Services at Harmony - Physical Therapy	2121 E. Harmony Road	Fort Collins	CO	Active
DSH060010Q	Child	DSH	POUDRE VALLEY HOSPITAL	UCHEALTH PT AND REHAB CLNC-PROSPEC - Physical Therapy	1106 E PROSPECT RD	FORT COLLINS	CO	Active
DSH060010R	Child	DSH	POUDRE VALLEY HOSPITAL	UCHEALTH CARDIAC REHAB - HARMONY - Cardiac Rehab	2121 E HARMONY RD	FORT COLLINS	CO	Active
DSH060010S	Child	DSH	POUDRE VALLEY HOSPITAL	PVH Sleep Lab - Sleep Lab	1107 S. Lemay Avenue	Fort Collins	CO	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	2121 E Harmony Road Suite 200 Fort Colliins, CO 80528-3401	2121 E Harmony Road Suite 200 Fort Collins, CO 80528-3401	2/5/2025 2:22 PM
Details	Last Recertification Date	Update	Recertification	9/6/2023 9:56:10 AM	8/14/2024 3:33:26 PM	8/14/2024 3:33 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1760492714	7/10/2024 4:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		CO	7/10/2024 4:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/7/2024 10:21 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000178613	5/7/2024 10:21 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	5/7/2024 10:21 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1558920561	5/7/2024 10:21 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	5/7/2024 10:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	9000178613 (CO)		9/6/2023 9:56 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1558920561 (CO)		9/6/2023 9:56 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 8:24:06 AM	9/6/2023 9:56:10 AM	9/6/2023 9:56 AM
Details	Last Recertification Date	Update	Recertification		9/1/2022 8:24:06 AM	9/1/2022 8:24 AM
Details	State	Update		Approved	Active	4/1/2022 12:01 AM
Addresses	Billing Address	Insert	Reinstatement		Poudre Valley Health Care Inc 2315 E Harmony Road 200 Fort Collins, CO 80528-8620	3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		9000178613	3/10/2022 2:28 PM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		CO	3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	05010004 (CO)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	HS387IP (AK)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	HS387OP (AK)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	POU0010N (AL)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	150091105 (AR)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	718207 (AZ)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	XHSP31461 (CA)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	008043238 (CT)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1760492714 (CT)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	090106700 (FL)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	192798108A (GA)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	541583 (HI)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1760492714 (ID)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	0028988 (ID)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	841262971001 (IL)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	100035780A (IN)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	100102830A (KS)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	7100012550 (KY)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1746835 (LA)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	110027699A (MA)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	449200500 (MD)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1760492714 (ME)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	30-4814376 (MI)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	40-4814385 (MI)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	037348600 (MN)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1760492714 (MO)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	02674210 (MS)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1760492714 (MT)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	9600010 (NC)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	01718 (ND)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	84126297100 (NE)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	4077504 (NJ)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	A1049 (NM)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1760492714 (NV)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	01615970 (NY)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	3146732 (OH)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	200128600A (OK)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	129262 (OR)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	0009091400001 (PA)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	11286A (SC)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	10609B (SC)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1760492714 (SD)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	0060010 (TN)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	071692001 (TX)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	841262971019 (UT)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	010080789 (VA)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	0060010 (VT)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1018372 (WA)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	80534600 (WI)		3/10/2022 2:28 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	119252300 (WY)		3/10/2022 2:28 PM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1558920561	3/10/2022 2:28 PM
Medicaid Billing	NPI: State	Insert	Reinstatement		CO	3/10/2022 2:28 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1760492714 ( )		3/10/2022 2:28 PM
Contacts	Authorizing Official	Update	Reinstatement	Doughty, Stephanie Chief Financial Officer Poudre Valley Hospital 9702377003	Thompson, David Charles Chief Financial Officer Poudre Valley Health Care, Inc. 9702377011	3/10/2022 2:28 PM
Contacts	Signed By	Update	Reinstatement	Doughty, Stephanie Chief Financial Officer Poudre Valley Hospital 9702377003	Thompson, David Charles Chief Financial Officer Poudre Valley Health Care, Inc. 9702377011	3/10/2022 2:28 PM
Contacts	Primary Contact	Update	Reinstatement	Good, Rodney Sr Director Pharmacy Services Poudre Valley Hospital 9702139246	Harmon, Andrew Director of Pharmacy Poudre Valley Health Care, Inc. 9704958054	3/10/2022 2:28 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	1/1/2018 12:00:00 AM		3/10/2022 2:28 PM
Dates	Participating Approval Date	Update	Reinstatement	6/13/2017 12:00:00 AM	3/10/2022 2:28:20 PM	3/10/2022 2:28 PM
Details	State	Update	Reinstatement	Terminated	Approved	3/10/2022 2:28 PM
Dates	Registration Date	Update	Reinstatement	6/10/2017 12:00:00 AM	3/9/2022 6:21:16 PM	3/10/2022 2:28 PM
Dates	Signed By Date	Update	Reinstatement	6/10/2017 12:00:00 AM	3/9/2022 6:56:41 PM	3/10/2022 2:28 PM
Dates	Start Date	Update	Reinstatement	7/1/2017 12:00:00 AM	4/1/2022 12:00:00 AM	3/10/2022 2:28 PM
Terminations	Termination Date	Update	Reinstatement	1/1/2018 12:00:00 AM		3/10/2022 2:28 PM
Terminations	Termination Effective Date	Update	Reinstatement	1/1/2018 12:00:00 AM		3/10/2022 2:28 PM
Terminations	Termination Reason	Update	Reinstatement	Failure to recertify		3/10/2022 2:28 PM
Details	Comments Public	Insert	Reinstatement		Participated starting on 7/1/2017; Terminated on 1/1/2018; Reinstated on 4/1/2022.	3/10/2022 10:00 AM
Details	State	Update		To Be Terminated	Terminated	1/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		1/1/2018 12:00:00 AM	12/7/2017 11:30 AM
Details	State	Update	Recertification	Active	To Be Terminated	12/7/2017 11:30 AM
Terminations	Termination Date	Update	Recertification		1/1/2018 12:00:00 AM	12/7/2017 11:30 AM
Terminations	Termination Effective Date	Update	Recertification		1/1/2018 12:00:00 AM	12/7/2017 11:30 AM
Terminations	Termination Reason	Update	Recertification		Failure to recertify	12/7/2017 11:30 AM
Contacts	Primary Contact	Update	Profile Change Request	Good, Rodney Sr Director Pharmacy Services Poudre Valley Hospital 9706243372	Good, Rodney Sr Director Pharmacy Services Poudre Valley Hospital 9702139246	11/15/2017 3:43 PM
Contacts	Primary Contact	Update		Good, Rodney Sr Director Pharmacy Services 9706243372	Good, Rodney Sr Director Pharmacy Services Poudre Valley Hospital 9706243372	11/15/2017 3:13 PM
Contacts	Authorizing Official	Update		Doughty, Stephanie Chief Financial Officer 9702377003	Doughty, Stephanie Chief Financial Officer Poudre Valley Hospital 9702377003	10/23/2017 5:13 PM
Contacts	Signed By	Update		Doughty, Stephanie Chief Financial Officer 9702377003	Doughty, Stephanie Chief Financial Officer Poudre Valley Hospital 9702377003	10/23/2017 5:13 PM
Contacts	Primary Contact	Insert			Good, Rodney Sr Director Pharmacy Services 9706243372	8/10/2017 8:13 AM
Contacts	Authorizing Official	Insert			Doughty, Stephanie Chief Financial Officer 9702377003	8/10/2017 8:13 AM
Contacts	Signed By	Insert			Doughty, Stephanie Chief Financial Officer 9702377003	8/10/2017 8:13 AM
Addresses	Main Address	Insert			2121 E Harmony Road Suite 200 Fort Colliins, CO 80528-3401	6/14/2017 3:11 PM
Addresses	Billing Address	Insert			Poudre Valley Health Care Inc 2315 E Harmony Road Suite 200 Fort Collins, CO 80528-8620	6/14/2017 3:11 PM
Dates	Participating Approval Date	Update			6/13/2017 12:00:00 AM	6/13/2017 5:48 PM
Details	State	Update		Pending	Active	6/13/2017 5:48 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	6/13/2017 5:48 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_77621	DSH060010D	6/13/2017 9:53 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_77621	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			05010004	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			CO	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			HS387IP	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			AK	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			HS387OP	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			AK	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			POU0010N	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			AL	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			150091105	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			AR	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			718207	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			AZ	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			XHSP31461	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			CA	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			008043238	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			CT	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1760492714	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			CT	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			090106700	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			FL	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			192798108A	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			GA	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			541583	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			HI	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1760492714	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			ID	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			0028988	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			ID	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			841262971001	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			IL	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			100035780A	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			IN	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			100102830A	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			KS	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			7100012550	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			KY	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1746835	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			LA	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			110027699A	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			MA	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			449200500	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			MD	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1760492714	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			ME	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			30-4814376	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			MI	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			40-4814385	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			MI	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			037348600	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			MN	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1760492714	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			MO	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			02674210	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			MS	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1760492714	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			MT	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			9600010	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			NC	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			01718	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			ND	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			84126297100	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			NE	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			4077504	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			NJ	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			A1049	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			NM	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1760492714	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			NV	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			01615970	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			NY	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			3146732	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			OH	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			200128600A	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			OK	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			129262	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			OR	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			0009091400001	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			PA	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			11286A	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			SC	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			10609B	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			SC	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1760492714	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			SD	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			0060010	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			TN	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			071692001	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			TX	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			841262971019	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			UT	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			010080789	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			VA	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			0060010	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			VT	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			1018372	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			WA	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			80534600	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			WI	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			119252300	6/10/2017 3:01 PM
Medicaid Billing	Medicaid: State	Insert			WY	6/10/2017 3:01 PM
Medicaid Billing	NPI: Number	Insert			1760492714	6/10/2017 3:01 PM
Details	Last Recertification Date	Insert				6/10/2017 3:01 PM
Details	Grant Number	Insert				6/10/2017 3:01 PM
Details	340B ID	Insert				6/10/2017 3:01 PM
Details	Is Authorizing Official EHB Data	Insert				6/10/2017 3:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert				6/10/2017 3:01 PM
Details	Medicare Provider Number	Insert			060010	6/10/2017 3:01 PM
Details	Entity Name	Insert			POUDRE VALLEY HOSPITAL	6/10/2017 3:01 PM
Details	Program Code	Insert			DSH	6/10/2017 3:01 PM
Details	Entity Subname	Insert			Heart Center	6/10/2017 3:01 PM
Dates	Participating Approval Date	Insert				6/10/2017 3:01 PM
Details	State	Insert			Pending	6/10/2017 3:01 PM
Dates	Registration Date	Insert			6/10/2017 12:00:00 AM	6/10/2017 3:01 PM
Dates	Signed By Date	Insert			6/10/2017 12:00:00 AM	6/10/2017 3:01 PM
Dates	Start Date	Insert				6/10/2017 3:01 PM
Terminations	Termination Comments	Insert				6/10/2017 3:01 PM
Terminations	Termination Date	Insert				6/10/2017 3:01 PM
Terminations	Termination Effective Date	Insert				6/10/2017 3:01 PM
Terminations	Termination Reason	Insert				6/10/2017 3:01 PM