Covered Entity Details

DSH220033AB BEVERLY HOSPITAL (Active) - information as of 4/28/2025 12:42:29 AM

Main Details

Name

BEVERLY HOSPITAL

Subdivision Name

LAHEY OUTPATIENT CENTER DANVERS / DAN OCCUPTNL THRPY

Type

Disproportionate Share Hospital

Rural

340B ID

DSH220033AB

Medicare Provider Number

220033

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2017

Participating Start Date

10/1/2017

Participating Approval Date

7/24/2017

Last Recertification Date

8/30/2024

Contacts

Authorizing Official

Beverly Hospital
Gregory Beaumier, CFO - Beverly Hospital
(978) 816-2587

Primary Contact

BILH
Jennifer Rossi, 340B Director of Compliance and Advocacy
(207) 266-9127

Addresses

Street Address

480 Maple Street
Suite 202
Danvers, MA 01923

Billing Address

Beverly Hospital
85 Herrick Street
Beverly, MA 01915

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
MA	MA-110026356-B,MA-110026356-A,MA-110026356-D	1316917941

Shipping Addresses

Shipping Address 1

Beverly Hospital
85 Herrick Street
Beverly, MA 01915

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
Contract Detail	CVS PHARMACY, INC.	DBA: CVS/PHARMACY # 01899	65 BOSTON STREET	LYNN	MA	01904	04/03/2019	07/01/2019		07/01/2019	07/15/2019
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/18/2023	07/01/2023		07/01/2024	07/01/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH220033A	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL	298 WASHINGTON ST.	GLOUCESTER	MA	Active
DSH220033AA	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN NUCLEAR MEDICINE	480 Maple Street	Danvers	MA	Terminated
DSH220033AB	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN OCCUPTNL THRPY	480 Maple Street	Danvers	MA	Active
DSH220033AC	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN OPERATING ROOM	480 Maple Street	Danvers	MA	Active
DSH220033AD	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN PHYSICAL THERAPY	480 Maple Street	Danvers	MA	Active
DSH220033AE	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN PREADMIT TEST	480 Maple Street	Danvers	MA	Active
DSH220033AF	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN ULTRASOUND	480 Maple Street	Danvers	MA	Active
DSH220033AG	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN VASCULAR LAB	480 maple street	Danvers	MA	Active
DSH220033AK	Child	DSH	BEVERLY HOSPITAL	BEVERLY HOSPITAL 83 HERRICK ST / BEV WH LABORATORY	83 HERRICK ST	Beverly	MA	Terminated
DSH220033AL	Child	DSH	BEVERLY HOSPITAL	BAYRIDGE HOSPITAL / BAY EMERGENCY PSYCH	60 Granite St	Lynn	MA	Active
DSH220033AM	Child	DSH	BEVERLY HOSPITAL	BAYRIDGE HOSPITAL / BAY LABORATORY	60 Granite St	Lynn	MA	Terminated
DSH220033AN	Child	DSH	BEVERLY HOSPITAL	BAYRIDGE HOSPITAL / BAY PSYCHIATRY	60 Granite St	Lynn	MA	Active
DSH220033AP	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH BLOOD BANK	298 Washington Street	Gloucester	MA	Terminated
DSH220033AQ	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH CHEMISTRY	298 Washington Street	Gloucester	MA	Terminated
DSH220033AR	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH CT SCAN	298 Washington St	Gloucester	MA	Active
DSH220033AS	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / Discover Psychiatric Clinic	298 Washington Street	Gloucester	MA	Active
DSH220033AT	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH LAB PHLEBOTOMY	298 Washington Street	Gloucester	MA	Terminated
DSH220033AU	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH MAMMOGRAPHY	298 Washington Street	Gloucester	MA	Active
DSH220033AV	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH MICROBIOLOGY	298 Washington Street	Gloucester	MA	Terminated
DSH220033AW	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH RESP THERAPY	298 Washington Street	Gloucester	MA	Active
DSH220033AX	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH SPEECH PATHOLOGY	298 Washington Street, Gloucester, MA 01930	Gloucester	MA	Active
DSH220033AY	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH EMERGENCY	298 Washington Street	Gloucester	MA	Active
DSH220033AZ	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH ENDOSCOPY	298 Washington Street, Gloucester	Gloucester	MA	Terminated
DSH220033B	Child	DSH	BEVERLY HOSPITAL	BAYRIDGE HOSPITAL	60 GRANITE STREET	LYNN	MA	Active
DSH220033BA	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH GERIATRICS	298 Washington Street	Gloucester	MA	Active
DSH220033BB	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH HEMATOLOGY	298 Washington Street	Gloucester	MA	Terminated
DSH220033BC	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH IV INFUSION ROOM	298 Washington Street	Gloucester	MA	Active
DSH220033BD	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH NUCLEAR MEDICINE	298 Washington Street	Gloucester	MA	Active
DSH220033BE	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH ONCOLOGY SVCS	298 Washington Street	Gloucester	MA	Active
DSH220033BF	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital / AGH OPERATING ROOM	298 Washington Street, Gloucester, MA 01930	Gloucester	MA	Terminated
DSH220033BG	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / AGH ULTRASOUND	298 Washington Street	Gloucester	MA	Active
DSH220033BH	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL - UROLOGY - UROLOGY	298 Washington Street	Gloucester	MA	Terminated
DSH220033BJ	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS - DAN PSYCH OP SVCS - PSYCHOLOGY/PSYCHIATRIC	480 Maple Street	Danvers	MA	Active
DSH220033BK	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS - DAN DIABETES CARE CENTER - ENDOCRINOLOGY	480 Maple Street	Danvers	MA	Active
DSH220033BL	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL - ENDOCRINOLOGY - ENDOCRINOLOGY	298 Washington Street	Gloucester	MA	Active
DSH220033BM	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL - CARDIOLOGY - CARDIOLOGY	298 Washington Street	Gloucester	MA	Active
DSH220033BN	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS - INFECTIOUS DISEASE - INFECTIOUS DISEASE	480 Maple Street	Danvers	MA	Active
DSH220033BP	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL - AGH GENERAL INTERNAL MED	298 WASHINGTON STREET	GLOUCESTER	MA	Active
DSH220033BQ	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL - GASTROENTEROLOGY - GASTROENTEROLOGY	298 Washington Street	Gloucester	MA	Terminated
DSH220033BR	Child	DSH	BEVERLY HOSPITAL	BAYRIDGE HOSPITAL - BAY PSYCH FLOOR2 - PSYCHIATRY	60 Granite Street	Lynn	MA	Active
DSH220033BS	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS - DERMATOLGY - DERMATOLGY AND MOHS SURGERY	480 Maple Street	Danvers	MA	Active
DSH220033BT	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL - INFECTIOUS DISEASE - INFECTIOUS DISEASE	298 Washington Street	Gloucester	MA	Active
DSH220033BU	Child	DSH	BEVERLY HOSPITAL	Danvers Geriatrics - Gerontology	480 Maple Street	Danvers	MA	Active
DSH220033BV	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital Pulmonary - Pulmonology	298 Washington Street	Gloucester	MA	Terminated
DSH220033BW	Child	DSH	BEVERLY HOSPITAL	Danvers Cardiology - Cardiology	480 Maple Street	Danvers	MA	Active
DSH220033BX	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS - PAIN CENTER	480 MAPLE STREET	DANVERS	MA	Active
DSH220033BY	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Pain Center	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033BZ	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Cardiac Rehabilitation	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033C	Child	DSH	BEVERLY HOSPITAL	BEVERLY HOSPITAL AT DANVERS	480 MAPLE ST	DANVERS	MA	Active
DSH220033CA	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Supplies Rehab Services	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033CB	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Ophthalmology	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033CC	Child	DSH	BEVERLY HOSPITAL	Women's Health and Medical Arts Building - Dermatology & Mohs surgery	Beverly Hospital	Beverly	MA	Active
DSH220033CD	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - LMI Diabetes Center	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033CE	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Ambulatory PACU	Lahey Outpatient Center Danvers	Danvers	MA	Active
DSH220033CF	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Post Anesthesia Care Unit	Lahey Outpatient Center Danvers	Danvers	MA	Active
DSH220033CG	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Supplies Rehab Services	Lahey Outpatient Center Danvers	Danvers	MA	Active
DSH220033CH	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Implantable Devices Surgery	Lahey Outpatient Center Danvers	Danvers	MA	Active
DSH220033CJ	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Electrocardiology	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033CK	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Anesthesiology	Lahey Outpatient Center Danvers	Danvers	MA	Active
DSH220033CL	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Occupational Therapy	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033CM	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Dermatology & Mohs surgery	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033CN	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Supplies Surgery	Lahey Outpatient Center Danvers	Danvers	MA	Active
DSH220033CP	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Diagnostic Radiology	Addison Gilbert Hospital	Gloucester	MA	Active
DSH220033CQ	Child	DSH	BEVERLY HOSPITAL	Beverly Hospital Burlington Campus - Rheumatology	67 South Bedford Road	Burlington	MA	Active
DSH220033CR	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Cardiac Rehabilitation	Lahey Outpatient Center Danvers	Danvers	MA	Active
DSH220033CS	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Vein Care Clinic	Lahey Outpatient Center Danvers	Danvers	MA	Active
DSH220033CT	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Intravenous therapy	298 Washington St.	Gloucester	MA	Active
DSH220033CU	Child	DSH	BEVERLY HOSPITAL	Beverly Hospital Burlington Campus - Endocrinology	67 South Bedford Road	Burlington	MA	Active
DSH220033CV	Child	DSH	BEVERLY HOSPITAL	Beverly Hospital - Lahey Outpatient Services - Neurology	29 Mall Road	Burlington	MA	Active
DSH220033CW	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - Wound care center	298 Washington St.	Gloucester	MA	Active
DSH220033CX	Child	DSH	BEVERLY HOSPITAL	Addison Gilbert Hospital - LMI Anticoagulation Center	298 Washington Street	Gloucester	MA	Active
DSH220033CY	Child	DSH	BEVERLY HOSPITAL	Lahey Outpatient Center Danvers - Rheumatology	480 Maple Street	Danvers	MA	Active
DSH220033CZ	Child	DSH	BEVERLY HOSPITAL	Herrick - Oncology Services	85 Herrick Street	Beverly	MA	Active
DSH220033D	Child	DSH	BEVERLY HOSPITAL	BH WOUND AND HYPERBARIC MEDICAL CENTER	500 CUMMINGS CTR	BEVERLY	MA	Active
DSH220033E	Child	DSH	BEVERLY HOSPITAL	NORTH SHORE BIRTHING CENTER	79 HERRICK ST.	BEVERLY	MA	Terminated
DSH220033F	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTERS DANVERS / DAN GEN SURGERY	480 Maple Street	Danvers	MA	Active
DSH220033G	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN LMI ANTICOAG CTR	50 Mall Rd	Burlington	MA	Active
DSH220033H	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN LMI NUTRITION CTR	480 Maple Street	Danvers	MA	Terminated
DSH220033J	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN LMI RISK RED CTR	480 Maple Street	Danvers	MA	Terminated
DSH220033K	Child	DSH	BEVERLY HOSPITAL	Beverly Hospital Parkhurst Weight Management Center	75 Herrick St	Beverly	MA	Active
DSH220033L	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN SURG WEIGHT LOSS CTR	480 Maple Street	Danvers	MA	Active
DSH220033M	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTERS DANVERS / DAN UROLOGY	480 Maple Street	Danvers	MA	Terminated
DSH220033N	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN AMB DAY CARE	480 Maple Street	Danvers	MA	Active
DSH220033P	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTERS DANVERS / DAN AURORA MRI	480 Maple Street	Danvers	MA	Terminated
DSH220033Q	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTERS DANVERS / DAN BREAST HEALTH	480 Maple Street	Danvers	MA	Active
DSH220033R	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN CT SCAN	480 Maple Street	Danvers	MA	Active
DSH220033S	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN Radiology	480 Maple Street	Danvers	MA	Active
DSH220033T	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN LAB SERVICES	480 Maple Street	Danvers	MA	Terminated
DSH220033U	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN Lifestyle Management Institute CARDIAC REHAB	480 Maple Street	Danvers	MA	Active
DSH220033V	Child	DSH	BEVERLY HOSPITAL	ADDISON GILBERT HOSPITAL / OUTPATIENT PT	298 Washington Street	Gloucester	MA	Active
DSH220033W	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN Life style Management Institute ENDOCRINOLOGY	480 Maple Street	Danvers	MA	Active
DSH220033X	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN Life Style Management Institute PODIATRY	480 Maple Street	Danvers	MA	Active
DSH220033Y	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN MAMMOGRAPHY	480 Maple Street	Danvers	MA	Active
DSH220033Z	Child	DSH	BEVERLY HOSPITAL	LAHEY OUTPATIENT CENTER DANVERS / DAN MRI	480 Maple Street	Danvers	MA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	PC Change Request	Wood, Shawn J Director of System 340B Oversight Beth Israel Lahey Health 7813526685	Rossi, Jennifer 340B Director of Compliance and Advocacy BILH 2072669127	1/14/2025 1:59 PM
Details	Last Recertification Date	Update	Recertification	8/29/2023 8:08:59 AM	8/30/2024 10:08:53 AM	8/30/2024 10:08 AM
Details	Last Recertification Date	Update	Recertification	9/15/2022 1:10:12 PM	8/29/2023 8:08:59 AM	8/29/2023 8:08 AM
Contacts	Authorizing Official	Update	AO Change Request	Sands, Tom President Northeast Hospital 9788162580	Beaumier, Gregory CFO - Beverly Hospital Beverly Hospital 9788162587	8/9/2023 1:07 PM
Contacts	Primary Contact	Update	Group Change Request	Violette, Hope Director of Pharmacy 220033 9789223000-2612	Wood, Shawn J Director of System 340B Oversight Beth Israel Lahey Health 7813526685	3/31/2023 6:08 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 9:19:49 AM	9/15/2022 1:10:12 PM	9/15/2022 1:10 PM
Contacts	Authorizing Official	Update	AO Change Request	Nalls, Jacqueline D CFO NE Hospitals 9788162587	Sands, Tom President Northeast Hospital 9788162580	9/13/2022 10:54 AM
Contacts	Authorizing Official	Update	AO Change Request	Woodworth, Connie Vice President Finance Northeast Hospital Corporation 9789223000-2587	Nalls, Jacqueline D CFO NE Hospitals 9788162587	6/16/2022 12:46 PM
Details	Last Recertification Date	Update	Recertification	8/24/2020 3:04:47 PM	8/27/2021 9:19:49 AM	8/27/2021 9:19 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1316917941	8/24/2020 3:04 PM
Medicaid Billing	NPI: State	Insert	Recertification		MA	8/24/2020 3:04 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1316917941 ( )		8/24/2020 3:04 PM
Details	Last Recertification Date	Update	Recertification	8/28/2019 12:16:32 PM	8/24/2020 3:04:47 PM	8/24/2020 3:04 PM
Addresses	Main Address	Update	Change Request	480 Maple Street Danvers, MA 01923	480 Maple Street Suite 202 Danvers, MA 01923	10/21/2019 12:41 PM
Details	Last Recertification Date	Update	Recertification	8/20/2018 2:44:43 PM	8/28/2019 12:16:32 PM	8/28/2019 12:16 PM
Details	Last Recertification Date	Update	Recertification	11/16/2017 8:17:20 AM	8/20/2018 2:44:43 PM	8/20/2018 2:44 PM
Addresses	Shipping Address	Insert	Recertification		Beverly Hospital 85 Herrick Street Beverly, MA 01915	11/16/2017 8:17 AM
Details	Last Recertification Date	Update	Recertification		11/16/2017 8:17:20 AM	11/16/2017 8:17 AM
Contacts	Authorizing Official	Update		Woodworth, Connie Vice President Finance 9789223000-2587	Woodworth, Connie Vice President Finance Northeast Hospital Corporation 9789223000-2587	10/17/2017 1:43 PM
Contacts	Signed By	Update		Woodworth, Connie Vice President Finance 9789223000-2587	Woodworth, Connie Vice President Finance Northeast Hospital Corporation 9789223000-2587	10/17/2017 1:43 PM
Contacts	Primary Contact	Update		Violette, Hope Director of Pharmacy 9789223000-2612	Violette, Hope Director of Pharmacy 220033 9789223000-2612	10/10/2017 3:23 PM
Contacts	Primary Contact	Insert			Violette, Hope Director of Pharmacy 9789223000-2612	7/25/2017 4:17 PM
Contacts	Authorizing Official	Insert			Woodworth, Connie Vice President Finance 9789223000-2587	7/25/2017 4:17 PM
Contacts	Signed By	Insert			Woodworth, Connie Vice President Finance 9789223000-2587	7/25/2017 4:17 PM
Addresses	Main Address	Insert			480 Maple Street Danvers, MA 01923	7/25/2017 4:17 PM
Addresses	Billing Address	Insert			Beverly Hospital 85 Herrick Street Beverly, MA 01915	7/25/2017 4:17 PM
Details	State	Update		Approved	Active	7/25/2017 4:17 PM
Dates	Participating Approval Date	Update			7/24/2017 12:00:00 AM	7/24/2017 4:38 PM
Details	State	Update		Pending	Approved	7/24/2017 4:38 PM
Dates	Start Date	Update			10/1/2017 12:00:00 AM	7/24/2017 4:38 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_78278	DSH220033AB	7/13/2017 1:02 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_78278	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: Number	Insert			MA-110026356-B	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: State	Insert			MA	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: Number	Insert			MA-110026356-A	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: State	Insert			MA	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: Number	Insert			MA-110026356-D	7/11/2017 3:47 PM
Medicaid Billing	Medicaid: State	Insert			MA	7/11/2017 3:47 PM
Medicaid Billing	NPI: Number	Insert			1316917941	7/11/2017 3:47 PM
Details	Last Recertification Date	Insert				7/11/2017 3:47 PM
Details	Grant Number	Insert				7/11/2017 3:47 PM
Details	340B ID	Insert				7/11/2017 3:47 PM
Details	Is Authorizing Official EHB Data	Insert				7/11/2017 3:47 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/11/2017 3:47 PM
Details	Medicare Provider Number	Insert			220033	7/11/2017 3:47 PM
Details	Entity Name	Insert			BEVERLY HOSPITAL	7/11/2017 3:47 PM
Details	Program Code	Insert			DSH	7/11/2017 3:47 PM
Details	Entity Subname	Insert			LAHEY OUTPATIENT CENTER DANVERS / DAN OCCUPTNL THRPY	7/11/2017 3:47 PM
Dates	Participating Approval Date	Insert				7/11/2017 3:47 PM
Details	State	Insert			Pending	7/11/2017 3:47 PM
Dates	Registration Date	Insert			7/11/2017 12:00:00 AM	7/11/2017 3:47 PM
Dates	Signed By Date	Insert			7/11/2017 12:00:00 AM	7/11/2017 3:47 PM
Dates	Start Date	Insert				7/11/2017 3:47 PM
Terminations	Termination Comments	Insert				7/11/2017 3:47 PM
Terminations	Termination Date	Insert				7/11/2017 3:47 PM
Terminations	Termination Effective Date	Insert				7/11/2017 3:47 PM
Terminations	Termination Reason	Insert				7/11/2017 3:47 PM