| Details | State | Update | | To Be Terminated | Terminated | 4/1/2024 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Termination Request | | 4/1/2024 12:00:00 AM | 1/17/2024 9:43 AM |
| Details | State | Update | Termination Request | Active | To Be Terminated | 1/17/2024 9:43 AM |
| Terminations | Termination Comments | Update | Termination Request | | Inside the 4 walls. | 1/17/2024 9:43 AM |
| Terminations | Termination Date | Update | Termination Request | | 4/1/2024 12:00:00 AM | 1/17/2024 9:43 AM |
| Terminations | Termination Effective Date | Update | Termination Request | | 4/1/2024 12:00:00 AM | 1/17/2024 9:43 AM |
| Terminations | Termination Reason | Update | Termination Request | | Other | 1/17/2024 9:43 AM |
| Details | Last Recertification Date | Update | Recertification | 8/24/2022 9:45:36 AM | 8/15/2023 10:43:41 AM | 8/15/2023 10:43 AM |
| Details | Entity Name | Update | Change Request | UVA HEALTH PRINCE WILLIAM HOSPITAL | UVA HEALTH PRINCE WILLIAM MEDICAL CENTER | 6/16/2023 12:11 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2023 12:43 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 005495000 | 6/13/2023 12:43 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | MD | 6/13/2023 12:43 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 6/13/2023 12:43 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1417005760 | 6/13/2023 12:43 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | NC | 6/13/2023 12:43 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1417005760 | 6/13/2023 12:43 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MD | 6/13/2023 12:43 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1417005760 | 6/13/2023 12:43 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | NC | 6/13/2023 12:43 PM |
| Details | Entity Name | Update | Change Request | UVA HEALTH PRINCE WILLIAM MEDICAL CENTER | UVA HEALTH PRINCE WILLIAM HOSPITAL | 4/26/2023 7:33 AM |
| Details | Entity Name | Update | Change Request | UVA HEALTH PRINCE WILLIAM HOSPITAL | UVA HEALTH PRINCE WILLIAM MEDICAL CENTER | 3/20/2023 2:18 PM |
| Addresses | Billing Address | Insert | Change Request | | UVA Health System
8700 Sudley Road
Manassas, VA 20110 | 2/8/2023 10:06 AM |
| Addresses | Shipping Address | Insert | Change Request | | UVA Health System
8700 Sudley Road
Manassas, VA 20110 | 2/8/2023 10:06 AM |
| Contacts | Primary Contact | Update | Change Request | Corazzo, Elizabeth Anne
Manager Pharmacy 340B
Novant Health
3362770301 | DeAngelis, Jordan T
Director Pharmacy
UVA Health System
4349821950 | 2/8/2023 10:06 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Hansen, Elizabeth Corazzo
Supervisor Pharmacy 340B
Novant Health
3362770301 | Corazzo, Elizabeth Anne
Manager Pharmacy 340B
Novant Health
3362770301 | 2/7/2023 4:18 PM |
| Details | Entity Name | Update | Change Request | PRINCE WILLIAM HOSPITAL DBA NOVANT HEALTH PRINCE WILLIAM MEDICAL | UVA HEALTH PRINCE WILLIAM HOSPITAL | 11/17/2022 11:09 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2021 10:08:31 AM | 8/24/2022 9:45:36 AM | 8/24/2022 9:45 AM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2020 10:31:56 AM | 8/16/2021 10:08:31 AM | 8/16/2021 10:08 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Gardner, Geoffrey
SVP Finance
Novant Health
3367182078 | Wilmoth, Brian
Strategic Planning and Reimbursement Officer
UVA Health System
4342439802 | 8/10/2021 10:11 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | VA | 9/10/2020 10:31 AM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2019 11:13:37 AM | 9/10/2020 10:31:56 AM | 9/10/2020 10:31 AM |
| Contacts | Authorizing Official | Update | Change Request | Terrell, Cedric A
SVP Pharmacy Services
Novant Health, Inc.
7043840611 | Gardner, Geoffrey
SVP Finance
Novant Health
3367182078 | 2/4/2020 4:19 PM |
| Details | Last Recertification Date | Update | Recertification | | 9/6/2019 11:13:37 AM | 9/6/2019 11:13 AM |
| Details | State | Update | | Approved | Active | 10/1/2018 12:05 AM |
| Details | Entity Name | Update | Change Request | NOVANT HEALTH PRINCE WILLIAM MEDICAL | PRINCE WILLIAM HOSPITAL DBA NOVANT HEALTH PRINCE WILLIAM MEDICAL | 9/5/2018 3:30 PM |
| Contacts | Signed By | Insert | New Registration | | Terrell, Cedric A
SVP Pharmacy Services
Novant Health, Inc.
7043840611 | 7/11/2018 12:47 PM |
| Details | 340B ID | Update | New Registration | | DSH490045C | 7/11/2018 12:47 PM |
| Details | Entity Subname | Update | New Registration | NHUVA OP Wound Care | NHUVA OP Wound Care - Outpatient Wound Care | 7/11/2018 12:47 PM |
| Dates | Participating Approval Date | Update | New Registration | | 7/11/2018 12:47:09 PM | 7/11/2018 12:47 PM |
| Details | State | Update | New Registration | Pending | Approved | 7/11/2018 12:47 PM |
| Dates | Signed By Date | Update | New Registration | | 7/3/2018 4:40:20 PM | 7/11/2018 12:47 PM |
| Dates | Start Date | Update | New Registration | | 10/1/2018 12:00:00 AM | 7/11/2018 12:47 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Terrell, Cedric A
SVP Pharmacy Corporate
Novant Health, Inc.
7043840611 | Terrell, Cedric A
SVP Pharmacy Services
Novant Health, Inc.
7043840611 | 7/3/2018 4:53 PM |
| Addresses | Main Address | Insert | New Registration | |
8644 Sudley Rd
Suite 115
Manassas, VA 20110 | 7/2/2018 3:30 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | New Registration | | False | 7/2/2018 3:30 PM |
| Medicaid Billing | Medicaid: Number | Insert | New Registration | | 4900456 | 7/2/2018 3:30 PM |
| Medicaid Billing | Medicaid: State | Insert | New Registration | | VA | 7/2/2018 3:30 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | New Registration | | False | 7/2/2018 3:30 PM |
| Medicaid Billing | Medicaid: Number | Insert | New Registration | | 260537A | 7/2/2018 3:30 PM |
| Medicaid Billing | Medicaid: State | Insert | New Registration | | VA | 7/2/2018 3:30 PM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1245745504 | 7/2/2018 3:30 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Terrell, Cedric A
SVP Pharmacy Corporate
Novant Health, Inc.
7043840611 | 7/2/2018 3:30 PM |
| Contacts | Primary Contact | Insert | New Registration | | Hansen, Elizabeth Corazzo
Supervisor Pharmacy 340B
Novant Health
3362770301 | 7/2/2018 3:30 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Details | Grant Number | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Details | 340B ID | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Details | Medicare Provider Number | Insert | New Registration | | 490045 | 7/2/2018 3:30 PM |
| Details | Entity Name | Insert | New Registration | | NOVANT HEALTH PRINCE WILLIAM MEDICAL | 7/2/2018 3:30 PM |
| Details | Program Code | Insert | New Registration | | DSH | 7/2/2018 3:30 PM |
| Details | Entity Subname | Insert | New Registration | | NHUVA OP Wound Care | 7/2/2018 3:30 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Details | State | Insert | New Registration | | Pending | 7/2/2018 3:30 PM |
| Dates | Registration Date | Insert | New Registration | | 7/2/2018 3:30:15 PM | 7/2/2018 3:30 PM |
| Dates | Signed By Date | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Dates | Start Date | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Terminations | Termination Date | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 7/2/2018 3:30 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 7/2/2018 3:30 PM |