Covered Entity Details

DSH330233U BROOKDALE HOSPITAL MEDICAL CENTER (Active) - information as of 4/25/2025 5:41:02 PM

Main Details

Name

BROOKDALE HOSPITAL MEDICAL CENTER

Subdivision Name

BFCC at Bristol Cardiology - Cardiology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH330233U

Medicare Provider Number

330233

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/13/2017

Participating Start Date

1/1/2018

Participating Approval Date

11/1/2017

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Brookdale Hospital Medical Center
Diana Sullivan, VP
(718) 240-7449

Primary Contact

Brookdale Hospital
Johnny Ha, Director of Pharmacy
(718) 240-5994

Addresses

Street Address

1235 Linden Blvd
Brooklyn, NY 11212

Billing Address

Brookdale Hospital Medical Center
One Brookdale Plaza
Brooklyn, NY 11212

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
NY	00243572	1346380870

Shipping Addresses

Shipping Address 1

Brookdale Hospital Medical Center
ONE BROOKDALE PLAZA
BROOKLYN, NY 11212

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	BROOKDALERX, INC.	1275 LINDEN BLVD	ATTN: SUPERVISING PHARMACIST	BROOKLYN	NY	11212	01/11/2018	04/01/2018	01/11/2018
Contract Detail	BROOKDALERX, INC.	URGENT CARE RX	1235 LINDEN BLVD	BROOKLYN	NY	11212	01/11/2018	04/01/2018	01/11/2018
Contract Detail	LINDEN PHARMA INC	DBA: LINDEN PHARMACY	1368 LINDEN BLVD	BROOKLYN	NY	11212	01/11/2018	04/01/2018	01/11/2018

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH330233A	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC OF BRISTOL STREET	1235 LINDEN BOULEVARD	BROOKLYN	NY	Active
DSH330233AA	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC OR - IMC OR	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233AB	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-GASTRO INTESTINAL - GASTRO INTESTINAL	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AC	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KINGSBROOK JEWISH MEDICAL CENTER - MAIN	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AD	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-RECOVERY ROOM - KJMC-RECOVERY ROOM	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AE	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-ED - KJMC-ED	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AF	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-CARDIOLOGY - KJMC-CARDIOLOGY	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AG	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-AMB SURG - KJMC-AMB SURG	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AH	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-ORTHOPEDICS - KJMC-ORTHOPEDICS	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AJ	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-OR - KJMC-OR	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AK	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-PODIATRY - KJMC-PODIATRY	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AL	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-ENDOSCOPY - KJMC-ENDOSCOPY	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AM	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-CHEMO INFUSION CENTER - KJMC-CHEMO INFUSION CENTER	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AN	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-DIALYSIS - KJMC-DIALYSIS	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AP	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-PAIN CLINIC - KJMC-PAIN CLINIC	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AQ	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-WOUND CARE - KJMC-WOUND CARE	585 SCHENECTADY AVENUE	BROOKLYN	NY	Terminated
DSH330233AR	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Asthma - Asthma Clinic	528 Prospect Place	BROOKLYN	NY	Active
DSH330233AS	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Hand Surgery - Hand Surgery	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233AT	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Pediatric Surgery - Pediatric Surgery	1545 ATLANTIC AVENUE	BROOKLYN	NY	Terminated
DSH330233AU	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Endocrinology - Endocrinology	528 Prospect Place	BROOKLYN	NY	Active
DSH330233AV	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Cardiology - CARDIOLOGY	528 Prospect Place	BROOKLYN	NY	Active
DSH330233AW	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Diabetes - Diabetes	528 Prospect Place	BROOKLYN	NY	Active
DSH330233AX	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Dermatology - Dermatology	528 Prospect Place	BROOKLYN	NY	Active
DSH330233AY	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Gynecology - Gynecology	528 Prospect Place	BROOKLYN	NY	Active
DSH330233AZ	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Interfaith Dental Center - Dental	1536 BEDFORD AVE	BROOKLYN	NY	Active
DSH330233B	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	Brookdale Family Care Center - Pennsylvania Ave Clinic	1110 Pennsylvania Avenue	Brooklyn	NY	Active
DSH330233BA	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker General Pediatrics - Pediatric	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BB	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Vascular - Vascular	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BC	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker ENT - ENT	528 Prospect Place	BROOKLYN	NY	Terminated
DSH330233BD	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Gastro-Intestinal - Gastro-Intestinal	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BE	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Breast - Breast Clinic	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BF	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Pediatric Sickle Cell - Pediatric Sickle Cell	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BG	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Hematology - Hematology	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BH	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Podiatry - Podiatry	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BJ	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC-METHADONE MAINTENANCE TREATMENT PROGRAM - METHADONE MAINTENANCE TREATMENT PROGRAM	882 BERGEN STREET	BROOKLYN	NY	Active
DSH330233BK	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Adult Sickle Cell - Adult Sickle Cell	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BL	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Allergy - Allergy Clinic	528 Prospect Place	BROOKLYN	NY	Terminated
DSH330233BM	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC-RECOVERY ROOM - IMC-RECOVERY ROOM	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233BN	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Pediatric Neurology - Pediatric Neurology	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BP	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker General Medicine - General Medicine	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BQ	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Tuberculosis - Tuberculosis Clinic	1545 ATLANTIC AVENUE	BROOKLYN	NY	Terminated
DSH330233BR	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC-CENTER FOR MENTAL HEALTH - CENTER FOR MENTAL HEALTH	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233BS	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Physical Therapy - Physical Therapy	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BT	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC RADIOLOGY - IMC RADIOLOGY	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233BU	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-INTERFAITH MEDICAL CENTER - MAIN	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233BV	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC CARDIAC CATH-LAB - IMC CARD-CATH LAB	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233BW	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC-Chemical Dependency Outpatient Services - Chemical Dependency Outpatient Services	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233BX	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker General Urology - Urology	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BY	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Plastic Surgery - Plastic Surgery	528 Prospect Place	BROOKLYN	NY	Active
DSH330233BZ	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Pediatric Ophthalmology - Pediatric Ophthalmology	528 Prospect Place	BROOKLYN	NY	Active
DSH330233C	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	Brookdale Urgent Care Center	1235 Linden Boulevard	Brooklyn	NY	Active
DSH330233CA	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Pediatric Urology - Pediatric Urology	528 Prospect Place	BROOKLYN	NY	Terminated
DSH330233CB	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Ophthalmology - Ophthalmology	528 Prospect Place	BROOKLYN	NY	Active
DSH330233CC	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC-EMERGENCY DEPARTMENT - IMC-EMERGENCY DEPARTMENT	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233CD	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Neurology - Neurology	1545 ATLANTIC AVENUE	BROOKLYN	NY	Active
DSH330233CE	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Wound Care - Wound Care	1545 ATLANTIC AVENUE	BROOKLYN	NY	Terminated
DSH330233CF	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker General Chest - Chest Clinic	528 Prospect Place	BROOKLYN	NY	Terminated
DSH330233CG	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-IMC-Primary Care/HIV Clinic - HIV Clinic	880 BERGEN STREET	BROOKLYN	NY	Active
DSH330233CH	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Orthopedic Surgery - Orthopedic Surgery	528 Prospect Place	BROOKLYN	NY	Active
DSH330233CJ	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Arthritis - Arthritis	528 Prospect Place	BROOKLYN	NY	Active
DSH330233CK	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Pediatric Cardiology - Pediatric Cardiology	528 Prospect Place	BROOKLYN	NY	Terminated
DSH330233CL	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-KJMC-Pierre Toussaint Family Health Center - Family Health Center	1110 Eastern Parkway	BROOKLYN	NY	Active
DSH330233CM	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Integrated Behavioral Health Clinic - Integrated Behavioral Health	528 Prospect Place	BROOKLYN	NY	Active
DSH330233D	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Penn HEM/ONC - HEM/ONC	1110 Pennsylvania Ave	Brooklyn	NY	Active
DSH330233E	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Family Practice - Family Practice	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233F	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Neurology - Neurology	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233G	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Rheumatology - Rheumatology	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233H	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Penn GI - GI	1110 Pennsylvania Ave	Brooklyn	NY	Active
DSH330233J	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Penn Cardiology - Cardiology	1110 Pennsylvania Ave	Brooklyn	NY	Active
DSH330233K	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol GI - GI	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233L	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Urology - Urology	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233M	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Penn Podiatry - Podiatry	1110 Pennsylvania Ave	Brooklyn	NY	Active
DSH330233N	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Pediatric Urology - Pediatric Urology	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233P	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Penn Pediatrics - Pediatrics	1110 Pennsylvania Ave	Brooklyn	NY	Active
DSH330233Q	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Podiatry - Podiatry	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233R	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Penn GYN - GYN	1110 Pennsylvania Ave	Brooklyn	NY	Active
DSH330233S	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Pediatric Surgery - Pediatric Surgery	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233T	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol OB/GYN - OB/GYN	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233U	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Cardiology - Cardiology	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233V	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Penn Adult Endocrine - Adult Endocrine	1110 Pennsylvania Ave	Brooklyn	NY	Active
DSH330233W	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Penn General Surgery - General Surgery	1110 Pennsylvania Ave	Brooklyn	NY	Active
DSH330233X	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BFCC at Bristol Pediatrics - Pediatrics	1235 Linden Blvd	Brooklyn	NY	Active
DSH330233Y	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	Star Clinic - HIV/AIDS	9620 Church Ave	Brooklyn	NY	Active
DSH330233Z	Child	DSH	BROOKDALE HOSPITAL MEDICAL CENTER	BHMC-Bishop Walker Orthopedic Surgery - Orthopedic Surgery	880 Bergen Street	BROOKLYN	NY	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/23/2023 2:34:06 PM	8/26/2024 11:41:48 AM	8/26/2024 11:41 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 5:26:37 PM	8/23/2023 2:34:06 PM	8/23/2023 2:34 PM
Details	Last Recertification Date	Update	Recertification	8/17/2021 3:25:20 PM	8/29/2022 5:26:37 PM	8/29/2022 5:26 PM
Contacts	Authorizing Official	Update	Change Request	Palermo, Robert A. CFO Brookdale Hospital Medical Center 7182408515	Sullivan, Diana VP Brookdale Hospital Medical Center 7182407449	1/3/2022 8:50 AM
Details	Last Recertification Date	Update	Recertification	8/17/2020 12:06:49 PM	8/17/2021 3:25:20 PM	8/17/2021 3:25 PM
Medicaid Billing	NPI: State	Update	Recertification		NY	8/17/2020 12:06 PM
Details	Last Recertification Date	Update	Recertification	8/27/2019 10:56:35 AM	8/17/2020 12:06:49 PM	8/17/2020 12:06 PM
Addresses	Shipping Address	Insert	Change Request		Brookdale Hospital Medical Center ONE BROOKDALE PLAZA BROOKLYN, NY 11212	10/21/2019 10:55 AM
Details	Last Recertification Date	Update	Recertification	8/20/2018 2:51:59 PM	8/27/2019 10:56:35 AM	8/27/2019 10:56 AM
Contacts	Authorizing Official	Update	AO Change Request	Porter, James CFO Brookdale Hospital 7182405773	Palermo, Robert A. CFO Brookdale Hospital Medical Center 7182408515	3/7/2019 12:35 PM
Details	Last Recertification Date	Update	Recertification		8/20/2018 2:51:59 PM	8/20/2018 2:51 PM
Details	State	Update		Approved	Active	1/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Porter, James CFO Brookdale Hospital 7182405773	11/1/2017 12:44 PM
Details	340B ID	Update	New Registration		DSH330233U	11/1/2017 12:44 PM
Details	Entity Subname	Update	New Registration	BFCC at Bristol Cardiology	BFCC at Bristol Cardiology - Cardiology	11/1/2017 12:44 PM
Dates	Participating Approval Date	Update	New Registration		11/1/2017 4:44:28 PM	11/1/2017 12:44 PM
Details	State	Update	New Registration	Pending	Approved	11/1/2017 12:44 PM
Dates	Signed By Date	Update	New Registration		10/16/2017 11:36:01 AM	11/1/2017 12:44 PM
Dates	Start Date	Update	New Registration		1/1/2018 12:00:00 AM	11/1/2017 12:44 PM
Addresses	Main Address	Insert	New Registration		1235 Linden Blvd Brooklyn, NY 11212	10/13/2017 3:41 PM
Addresses	Billing Address	Insert	New Registration		Brookdale Hospital Medical Center One Brookdale Plaza Brooklyn, NY 11212	10/13/2017 3:41 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/13/2017 3:41 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		00243572	10/13/2017 3:41 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		NY	10/13/2017 3:41 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1346380870	10/13/2017 3:41 PM
Contacts	Primary Contact	Insert	New Registration		Ha, Johnny Director of Pharmacy Brookdale Hospital 7182405994	10/13/2017 3:41 PM
Contacts	Authorizing Official	Insert	New Registration		Porter, James CFO Brookdale Hospital 7182405773	10/13/2017 3:41 PM
Details	Last Recertification Date	Insert	New Registration			10/13/2017 3:41 PM
Details	Grant Number	Insert	New Registration			10/13/2017 3:41 PM
Details	340B ID	Insert	New Registration			10/13/2017 3:41 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/13/2017 3:41 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/13/2017 3:41 PM
Details	Medicare Provider Number	Insert	New Registration		330233	10/13/2017 3:41 PM
Details	Entity Name	Insert	New Registration		BROOKDALE HOSPITAL MEDICAL CENTER	10/13/2017 3:41 PM
Details	Program Code	Insert	New Registration		DSH	10/13/2017 3:41 PM
Details	Entity Subname	Insert	New Registration		BFCC at Bristol Cardiology	10/13/2017 3:41 PM
Dates	Participating Approval Date	Insert	New Registration			10/13/2017 3:41 PM
Details	State	Insert	New Registration		Pending	10/13/2017 3:41 PM
Dates	Registration Date	Insert	New Registration		10/13/2017 3:41:51 PM	10/13/2017 3:41 PM
Dates	Signed By Date	Insert	New Registration			10/13/2017 3:41 PM
Dates	Start Date	Insert	New Registration			10/13/2017 3:41 PM
Terminations	Termination Comments	Insert	New Registration			10/13/2017 3:41 PM
Terminations	Termination Date	Insert	New Registration			10/13/2017 3:41 PM
Terminations	Termination Effective Date	Insert	New Registration			10/13/2017 3:41 PM
Terminations	Termination Reason	Insert	New Registration			10/13/2017 3:41 PM