| Contacts | Authorizing Official | Update | Profile Change Request | FREY, CARRIE
Director of Finance
Aria Health
2156124313 | FREY, CARRIE
Director of Finance
Jefferson Health
2156124313 | 4/11/2025 8:54 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Ottemiller, Dustin
VP, Finance
Thomas Jefferson University Hospitals, Inc.
2155035219 | Ottemiller, Dustin
VP, Finance
Jefferson Health
2155035219 | 9/3/2024 11:17 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2023 6:46:52 PM | 8/19/2024 9:13:50 AM | 8/19/2024 9:13 AM |
| Addresses | Shipping Address | Insert | Change Request | | Jefferson Health Northeast - KoP
3500 Horizon Dr.
Room 1074
King of Prussia, PA 19406 | 7/1/2024 12:47 PM |
| Contacts | Primary Contact | Update | Change Request | Adams, Neal
Pharmacy Manager
Aria Health
2156125473 | Ottemiller, Dustin
VP, Finance
Thomas Jefferson University Hospitals, Inc.
2155035219 | 5/21/2024 7:26 AM |
| Addresses | Shipping Address | Insert | Change Request | | Jefferson Health Northeast
Knights & Red Lion Roads
Philadelphia, PA 19114 | 5/16/2024 7:22 AM |
| Addresses | Main Address | Update | Change Request |
KNIGHTS & RED LION ROADS
PHILADELPHIA, PA 19114 |
10800 Knights Rd.
PHILADELPHIA, PA 19114 | 5/16/2024 7:22 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2022 9:31:07 AM | 8/16/2023 6:46:52 PM | 8/16/2023 6:46 PM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2021 10:00:41 AM | 8/24/2022 9:31:07 AM | 8/24/2022 9:31 AM |
| Addresses | Shipping Address | Update | Change Request | Aria Health - Torresdale Campus
10800 Knights Rd.
Philadelphia, PA 19114 | Jefferson Health Northeast - Torresdale Campus
10800 Knights Rd.
Philadelphia, PA 19114 | 5/23/2022 7:11 AM |
| Addresses | Shipping Address | Update | Change Request | Aria Health - Frankford Campus
4900 Frankford Ave.
Philadelphia, PA 19124 | Jefferson Health Northeast - Frankford Campus
4900 Frankford Ave.
Philadelphia, PA 19124 | 5/23/2022 7:11 AM |
| Addresses | Shipping Address | Update | Change Request | Aria Health - Bucks County Campus
380 North Oxford Valley Rd.
Langhorne, PA 19047 | Jefferson Health Northeast - Bucks County Campus
380 North Oxford Valley Rd.
Langhorne, PA 19047 | 5/23/2022 7:11 AM |
| Addresses | Shipping Address | Update | Change Request | Aria Health - Frankford Campus
Frankford Avenue and Wakeling Street
Philadelphia, PA 19124 | Jefferson Health Northeast - Frankford Campus
Frankford Avenue and Wakeling Street
Philadelphia, PA 19124 | 5/23/2022 7:11 AM |
| Addresses | Billing Address | Update | Change Request | Aria Health
PO Box 8500 6395
Philadelphia, PA 19178-8639 | Jefferson Health Northeast
PO Box 8500 6395
Philadelphia, PA 19178-8639 | 5/23/2022 7:11 AM |
| Details | Entity Name | Update | Change Request | ARIA HEALTH | Jefferson Health Northeast | 5/23/2022 7:11 AM |
| Contacts | Authorizing Official | Update | Profile Change Request | FREY, CARRIE
Director of Finance
Aria Health
2157103755 | FREY, CARRIE
Director of Finance
Aria Health
2156124313 | 10/14/2021 8:04 AM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2020 8:37:35 AM | 8/16/2021 10:00:41 AM | 8/16/2021 10:00 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1801963343 | 8/20/2020 8:37 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | PA | 8/20/2020 8:37 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1407981327 ( ) | | 8/20/2020 8:37 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1801963343 ( ) | | 8/20/2020 8:37 AM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2019 8:08:50 AM | 8/20/2020 8:37:35 AM | 8/20/2020 8:37 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Degnan, William
Vice President of Finance
Aria Health
2157103741 | FREY, CARRIE
Director of Finance
Aria Health
2157103755 | 7/17/2020 3:25 PM |
| Contacts | Primary Contact | Update | Recertification | Webster, Dominic
Administrative Director - Pharmacy Services
Aria Health
2156124180 | Adams, Neal
Pharmacy Manager
Aria Health
2156125473 | 9/2/2019 8:08 AM |
| Details | Last Recertification Date | Update | Recertification | 8/27/2018 1:37:06 PM | 9/2/2019 8:08:50 AM | 9/2/2019 8:08 AM |
| Addresses | Shipping Address | Insert | Change Request | | Aria Health - Frankford Campus
Frankford Avenue and Wakeling Street
Philadelphia, PA 19124 | 8/9/2019 12:34 PM |
| Addresses | Shipping Address | Insert | Change Request | | Aria Health - Torresdale Campus
10800 Knights Rd.
Philadelphia, PA 19114 | 4/12/2019 4:44 PM |
| Addresses | Shipping Address | Insert | Change Request | | Aria Health - Frankford Campus
4900 Frankford Ave.
Philadelphia, PA 19124 | 4/12/2019 4:44 PM |
| Addresses | Shipping Address | Insert | Change Request | | Aria Health - Bucks County Campus
380 North Oxford Valley Rd.
Langhorne, PA 19047 | 4/12/2019 4:44 PM |
| Details | Last Recertification Date | Update | Recertification | 11/3/2017 8:19:22 AM | 8/27/2018 1:37:06 PM | 8/27/2018 1:37 PM |
| Details | Last Recertification Date | Update | Recertification | 10/24/2017 5:06:45 PM | 11/3/2017 8:19:22 AM | 11/3/2017 8:19 AM |
| Details | Last Recertification Date | Update | Recertification | | 10/24/2017 5:06:45 PM | 10/24/2017 5:06 PM |
| Contacts | Primary Contact | Update | New Registration | Webster, Dominic
Administrative Director - Pharmacy Services
2156124180 | Webster, Dominic
Administrative Director - Pharmacy Services
Aria Health
2156124180 | 10/12/2017 4:39 PM |
| Contacts | Authorizing Official | Update | | Degnan, William
Vice President of Finance
2157103741 | Degnan, William
Vice President of Finance
Aria Health
2157103741 | 10/12/2017 9:07 AM |
| Contacts | Signed By | Update | | Degnan, William
Vice President of Finance
2157103741 | Degnan, William
Vice President of Finance
Aria Health
2157103741 | 10/12/2017 9:07 AM |
| Contacts | Authorizing Official | Insert | | | Degnan, William
Vice President of Finance
2157103741 | 7/13/2017 7:04 PM |
| Contacts | Signed By | Insert | | | Degnan, William
Vice President of Finance
2157103741 | 7/13/2017 7:04 PM |
| Contacts | Primary Contact | Insert | | | Webster, Dominic
Administrative Director - Pharmacy Services
2156124180 | 7/13/2017 7:04 PM |
| Addresses | Main Address | Insert | | |
KNIGHTS & RED LION ROADS
PHILADELPHIA, PA 19114 | 7/13/2017 7:04 PM |
| Addresses | Billing Address | Insert | | | Aria Health
PO Box 8500 6395
Philadelphia, PA 19178-8639 | 7/13/2017 7:04 PM |
| Details | State | Update | | Approved | Active | 7/13/2017 7:04 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 7/13/2017 7:00 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 1007705250021 | 7/13/2017 7:00 PM |
| Medicaid Billing | Medicaid: State | Insert | | | PA | 7/13/2017 7:00 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1407981327 | 7/13/2017 7:00 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1801963343 | 7/13/2017 7:00 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | 4/13/2017 12:00:00 AM | | 7/13/2017 7:00 PM |
| Dates | Participating Approval Date | Update | | 4/26/2017 12:00:00 AM | 7/13/2017 12:00:00 AM | 7/13/2017 7:00 PM |
| Details | State | Update | | Terminated | Approved | 7/13/2017 7:00 PM |
| Dates | Registration Date | Update | | 4/13/2017 12:00:00 AM | 7/11/2017 12:00:00 AM | 7/13/2017 7:00 PM |
| Dates | Signed By Date | Update | | 4/13/2017 12:00:00 AM | 7/11/2017 12:00:00 AM | 7/13/2017 7:00 PM |
| Dates | Start Date | Update | | 7/1/2017 12:00:00 AM | 10/1/2017 12:00:00 AM | 7/13/2017 7:00 PM |
| Terminations | Termination Comments | Update | | Vendor is not ready to implement split-billing program. We will re-register in the next enrollment period, giving us more time to implement the program. | | 7/13/2017 7:00 PM |
| Terminations | Termination Date | Update | | 7/1/2017 12:00:00 AM | | 7/13/2017 7:00 PM |
| Terminations | Termination Effective Date | Update | | 4/13/2017 12:00:00 AM | | 7/13/2017 7:00 PM |
| Terminations | Termination Reason | Update | | Site closure | | 7/13/2017 7:00 PM |
| Dates | Last Date That 340B Drugs Purchased | Update | | | 4/13/2017 12:00:00 AM | 6/30/2017 7:25 AM |
| Details | State | Update | | Active | Terminated | 6/30/2017 7:25 AM |
| Terminations | Termination Comments | Update | | | Vendor is not ready to implement split-billing program. We will re-register in the next enrollment period, giving us more time to implement the program. | 6/30/2017 7:25 AM |
| Terminations | Termination Date | Update | | | 7/1/2017 12:00:00 AM | 6/30/2017 7:25 AM |
| Terminations | Termination Effective Date | Update | | | 4/13/2017 12:00:00 AM | 6/30/2017 7:25 AM |
| Terminations | Termination Reason | Update | | | Site closure | 6/30/2017 7:25 AM |
| Dates | Participating Approval Date | Update | | | 4/26/2017 12:00:00 AM | 4/26/2017 9:52 AM |
| Details | State | Update | | Pending | Active | 4/26/2017 9:52 AM |
| Dates | Start Date | Update | | | 7/1/2017 12:00:00 AM | 4/26/2017 9:52 AM |
| Details | 340B ID | Update | | ONLINE_REG_76935 | DSH390115 | 4/14/2017 1:46 PM |
| Details | 340B ID | Update | | | ONLINE_REG_76935 | 4/13/2017 5:01 PM |
| Details | Last Recertification Date | Insert | | | | 4/13/2017 5:01 PM |
| Details | Grant Number | Insert | | | | 4/13/2017 5:01 PM |
| Details | 340B ID | Insert | | | | 4/13/2017 5:01 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/13/2017 5:01 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/13/2017 5:01 PM |
| Details | Medicare Provider Number | Insert | | | 390115 | 4/13/2017 5:01 PM |
| Details | Entity Name | Insert | | | ARIA HEALTH | 4/13/2017 5:01 PM |
| Details | Program Code | Insert | | | DSH | 4/13/2017 5:01 PM |
| Details | Entity Subname | Insert | | | | 4/13/2017 5:01 PM |
| Dates | Participating Approval Date | Insert | | | | 4/13/2017 5:01 PM |
| Details | State | Insert | | | Pending | 4/13/2017 5:01 PM |
| Dates | Registration Date | Insert | | | 4/13/2017 12:00:00 AM | 4/13/2017 5:01 PM |
| Dates | Signed By Date | Insert | | | 4/13/2017 12:00:00 AM | 4/13/2017 5:01 PM |
| Dates | Start Date | Insert | | | | 4/13/2017 5:01 PM |
| Terminations | Termination Comments | Insert | | | | 4/13/2017 5:01 PM |
| Terminations | Termination Date | Insert | | | | 4/13/2017 5:01 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/13/2017 5:01 PM |
| Terminations | Termination Reason | Insert | | | | 4/13/2017 5:01 PM |