Covered Entity Details

PED363306-20 Dayton Children's Hospital (Active) - information as of 4/25/2025 6:31:46 PM

Main Details

Name

Dayton Children's Hospital

Subdivision Name

Outpatient Care Center - Springboro - Healthy Me CL at OCCS

Type

Children's Hospital

Rural

340B ID

PED363306-20

Medicare Provider Number

363306

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/12/2018

Participating Start Date

10/1/2018

Participating Approval Date

8/6/2018

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Dayton Children's
Benjamin Goodstein, VICE PRESIDENT and Chief Ambulatory Officer
(937) 641-3450

Primary Contact

Dayton Children's
Chad Meyers, Director of Ambulatory Pharmacy Services
(937) 641-4591

Addresses

Street Address

3333 West Tech Road
Miamisburg, OH 45342

Billing Address
Same as Street Address

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
OH	0465509	1457379448

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
PED363306-01	Child	PED	Dayton Children's Hospital	DAYTON CHILDREN'S SPECIALTY CARE CENTER-WARREN COUNTY-ENT	100 CAMPUS LOOP ROAD	FRANKLIN	OH	Terminated
PED363306-02	Child	PED	Dayton Children's Hospital	Outpatient Care Center Springboro - Urgent Care at OCCS	3333 WEST TECH ROAD	Miamisburg	OH	Active
PED363306-03	Child	PED	Dayton Children's Hospital	Child Health Pavillion - Dayton Child Peds TCHP	1010 Valley Street	Dayton	OH	Active
PED363306-04	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGBORO - XR OCCS	3333 WEST TECH RD	MIAMISBURG	OH	Active
PED363306-05	Child	PED	Dayton Children's Hospital	Speciality Clinics-Lima	967 Bellefontaine Avenue	Lima	OH	Terminated
PED363306-06	Child	PED	Dayton Children's Hospital	Dayton Children's Sports Medicine Clinic - Sports Medicine	One Children's Plaza	Dayton	OH	Terminated
PED363306-07	Child	PED	Dayton Children's Hospital	Dayton Children's Urology Clinic - Urology	One Children's Plaza	Dayton	OH	Terminated
PED363306-08	Child	PED	Dayton Children's Hospital	Outpatient Care Center Springboro - Ped ENT at OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-09	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro -Pulmonary at OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-10	Child	PED	Dayton Children's Hospital	Dayton Children's Plastic Surgery Clinic - Plastic Surgery	One Children's Plaza	Dayton	OH	Terminated
PED363306-100	Child	PED	Dayton Children's Hospital	DAYTON CHILDRENS HOSPITAL SOUTH - RHEUMATOLOGY AT OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-101	Child	PED	Dayton Children's Hospital	DAYTON CHILDRENS BEHAVIORAL HEALTH - DEVPEDS/AUTISM BHCNTR	76 REMICK BLVD	SPRINGBORO	OH	Terminated
PED363306-102	Child	PED	Dayton Children's Hospital	Kids Express - Springboro - KIDS EXPRESS CCS	662 N. Main St	Springboro	OH	Active
PED363306-103	Child	PED	Dayton Children's Hospital	DAYTON CHILDRENS HOSPITAL SOUTH - ENDOCRINOLOGY AT OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-104	Child	PED	Dayton Children's Hospital	DAYTON CHILDRENS HOSPITAL SOUTH - MED IMAGING AT OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-105	Child	PED	Dayton Children's Hospital	DAYTON CHILDRENS HOSPITAL SOUTH - SLEEP LAB AT OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-106	Child	PED	Dayton Children's Hospital	Behavioral Health Center Dayton - PSYCHIATRY AT BHDAY	700 E 1st Street	Dayton	OH	Active
PED363306-107	Child	PED	Dayton Children's Hospital	OHIO PEDIATRIC CARE ALLIANCE - HEALTHY ME CL AT PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-108	Child	PED	Dayton Children's Hospital	TROY OUTPATIENT CENTER - ENDOCRINOLOGY AT OCCT	865 W MARKET ST	TROY	OH	Active
PED363306-109	Child	PED	Dayton Children's Hospital	OHIO PEDIATRIC CARE ALLIANCE - ENDOCRINOLOGY AT PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-11	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Sleep Clinic OCCS	3333 West Tech Rd	Miamisburg	OH	Active
PED363306-110	Child	PED	Dayton Children's Hospital	THE CHILD HEALTH PAVILION - AYA (Adolescent and Young Adult Clinic) AT TCHP	1010 VALLEY ST	DAYTON	OH	Terminated
PED363306-111	Child	PED	Dayton Children's Hospital	Kids Express - Mason - KIDS EXPRESS MASON	8809 Wilkens Blvd	Mason	OH	Active
PED363306-112	Child	PED	Dayton Children's Hospital	Kids Express - West Chester - KIDS EXPRESS W CHESTER	7787 Cox Lane	West Chester	OH	Active
PED363306-113	Child	PED	Dayton Children's Hospital	Behavioral Health Center Dayton - BH Day TRTMNT Center	700 E 1st Street	Dayton	OH	Active
PED363306-114	Child	PED	Dayton Children's Hospital	HOPE CENTER - Dayton Child Peds Hope	1816 HARVARD BLVD	DAYTON	OH	Active
PED363306-115	Child	PED	Dayton Children's Hospital	DAYTON CHILDRENS HOSPITAL SOUTH - Neuromuscular OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Terminated
PED363306-116	Child	PED	Dayton Children's Hospital	BEAVERCREEK OUTPATIENT CARE CENTER - PULM DIAG LAB AT OCCB	1425 N FAIRFIELD RD	BEAVERCREEK	OH	Active
PED363306-117	Child	PED	Dayton Children's Hospital	BEAVERCREEK OUTPATIENT CARE CENTER - ORTHO REHAB AT OCCB	1425 N FAIRFIELD RD	BEAVERCREEK	OH	Active
PED363306-118	Child	PED	Dayton Children's Hospital	Kids Express - Beavercreek - KIDS EXPRESS BEAVERCK	3301 Dayton Xenia Rd	Beavercreek	OH	Active
PED363306-119	Child	PED	Dayton Children's Hospital	Kids Express - Centerville - KIDS EXPRESS CENTERVIL	6044 Wilmington Pike	Dayton	OH	Active
PED363306-12	Child	PED	Dayton Children's Hospital	Dayton Children's- Neurology Lab - Neurology	One Children's Plaza	Dayton	OH	Terminated
PED363306-13	Child	PED	Dayton Children's Hospital	Dayton Children's- Psychology Clinic - Psychology Clinic	One Children's Plaza	Dayton	OH	Terminated
PED363306-14	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro- Cardio Clinic at OCCS	3333 WEST TECH	MIAMISBURG	OH	Active
PED363306-15	Child	PED	Dayton Children's Hospital	Dayton Children's Sleep Clinic - Sleep Clinic	One Children's Plaza	Dayton	OH	Terminated
PED363306-16	Child	PED	Dayton Children's Hospital	Dayton Children's- Care Clinic - Care Clinic	One Children's Plaza	Dayton	OH	Terminated
PED363306-17	Child	PED	Dayton Children's Hospital	Dayton Children's Allergy Clinic - Allergy	One Children's Plaza	Dayton	OH	Terminated
PED363306-18	Child	PED	Dayton Children's Hospital	Dayton Children's- Cardiology Clinic - Cardiology	One Children's Plaza	Dayton	OH	Terminated
PED363306-19	Child	PED	Dayton Children's Hospital	Dayton Children's- Psychiatry Clinic - Psychiatry Clinic	One Children's Plaza	Dayton	OH	Terminated
PED363306-20	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Healthy Me CL at OCCS	3333 West Tech Road	Miamisburg	OH	Active
PED363306-21	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Allergy Clinic OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-22	Child	PED	Dayton Children's Hospital	Dayton Children's Emergency Department - Emergency	One Children's Plaza	Dayton	OH	Terminated
PED363306-23	Child	PED	Dayton Children's Hospital	Outpatient Care Center Warren County -Cardiology Clinic-Piqua - Cardiology Clinic	280 N. Looney Road	Piqua	OH	Terminated
PED363306-24	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Neurology at OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-25	Child	PED	Dayton Children's Hospital	Dayton Children's Pediatric ENT - ENT	One Children's Plaza	Dayton	OH	Terminated
PED363306-26	Child	PED	Dayton Children's Hospital	Dayton Children's Gastroenterology - Gastroenterology	One Children's Plaza	Dayton	OH	Terminated
PED363306-27	Child	PED	Dayton Children's Hospital	Dayton Children's Surgery Clinic - Surgery	One Children's Plaza	Dayton	OH	Terminated
PED363306-28	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro -Plastic Surgery OCCS	3333 West Tech Rd.	Miamisburg	OH	Terminated
PED363306-29	Child	PED	Dayton Children's Hospital	Dayton Children's Surgery - Surgery	One Children's Plaza	Dayton	OH	Terminated
PED363306-30	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro -Sports Med CL at OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-31	Child	PED	Dayton Children's Hospital	Dayton Children's- Cerebral Palsy Clinic - Cerebral Palsy	One Children's Plaza	Dayton	OH	Terminated
PED363306-32	Child	PED	Dayton Children's Hospital	Dayton Children's- Lipid Clinic - Lipid Clinic	One Children's Plaza	Dayton	OH	Terminated
PED363306-33	Child	PED	Dayton Children's Hospital	Outpatient Care Center Springboro -Dermatology - Dermatology	3333 West Tech Road	Miamisburg	OH	Terminated
PED363306-34	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro -Surg Clinic at OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-35	Child	PED	Dayton Children's Hospital	Outpatient Care Center - ED OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-36	Child	PED	Dayton Children's Hospital	Dayton Children's Ortho Rehab Services - Rehabilitation	One Children's Plaza	Dayton	OH	Terminated
PED363306-37	Child	PED	Dayton Children's Hospital	Dayton Children's Diabetes Clinic - Diabetes	One Children's Plaza	Dayton	OH	Terminated
PED363306-38	Child	PED	Dayton Children's Hospital	Dayton Children's Hem/Onc Clinic - Hem/Onc	One Children's Plaza	Dayton	OH	Terminated
PED363306-39	Child	PED	Dayton Children's Hospital	Dayton Children's Infectious Diseases - Infectious Diseases	One Children's Plaza	Dayton	OH	Terminated
PED363306-40	Child	PED	Dayton Children's Hospital	Dayton Children's- Nephrology Clinic - Nephrology	One Children's Plaza	Dayton	OH	Terminated
PED363306-41	Child	PED	Dayton Children's Hospital	Dayton Children's- Almost Home Unit - Almost Home Unit	One Children's Plaza	Dayton	OH	Terminated
PED363306-42	Child	PED	Dayton Children's Hospital	Dayton Children's- Specialty Clinic - Specialty Clini	One Children's Plaza	Dayton	OH	Terminated
PED363306-43	Child	PED	Dayton Children's Hospital	Dayton Children's Pulmonary Clinic - Pulmonary Clinic	One Children's Plaza	Dayton	OH	Terminated
PED363306-44	Child	PED	Dayton Children's Hospital	Dayton Children's- Audiology - Audiology	One Children's Plaza	Dayton	OH	Terminated
PED363306-45	Child	PED	Dayton Children's Hospital	Dayton Children's- Developmental Peds - Developmental Peds	One Children's Plaza	Dayton	OH	Terminated
PED363306-46	Child	PED	Dayton Children's Hospital	Dayton Children's- Cardiology Testing - Cardiology Testing	One Children's Plaza	Dayton	OH	Terminated
PED363306-47	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Pulm Diag Lab at OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-48	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Diabetes/Endocrinology at OCCS	3333 West Tech Road	Miamisburg	OH	Active
PED363306-49	Child	PED	Dayton Children's Hospital	Dayton Children's Sleep Lab - Sleep Lab	One Children's Plaza	Dayton	OH	Terminated
PED363306-50	Child	PED	Dayton Children's Hospital	Dayton Children's Pulmonary Diag Lab - Pulmonary Diag Lab	One Children's Plaza	Dayton	OH	Terminated
PED363306-51	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Audiology at OCCS	3333 West Tech Rd.	Miamisburg	OH	Active
PED363306-52	Child	PED	Dayton Children's Hospital	Outpatient Care Center Springboro-Hem/Onc Clinic - Hem/Onc	3333 West Tech Rd	Miamisburg	OH	Terminated
PED363306-53	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Gastroent at OCCS	3333 West Tech Road	Miamisburg	OH	Active
PED363306-54	Child	PED	Dayton Children's Hospital	Dayton Children's- Neurology Clinic - Neurology	One Children's Plaza	Dayton	OH	Terminated
PED363306-55	Child	PED	Dayton Children's Hospital	Dayton Children's- Radiology - -Radiology	One Children's Plaza	Dayton	OH	Terminated
PED363306-56	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGFIELD - Neurology at PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-57	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGFIELD - Cardio Clinic at PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-58	Child	PED	Dayton Children's Hospital	Dayton Childrens Warren County - SCCWC - Pulmonary Diagnostics	100 Campus Loop Road	Franklin	OH	Terminated
PED363306-59	Child	PED	Dayton Children's Hospital	Specialty Care Center - Lima - Gastroent at SCL	967 Bellefontaine Avenue	Lima	OH	Active
PED363306-60	Child	PED	Dayton Children's Hospital	Specialty Care Center - Lima - Hematology Clinic	967 Bellefontaine Avenue	Lima	OH	Active
PED363306-61	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGFIELD - Diabetes/Endocrinology at PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-62	Child	PED	Dayton Children's Hospital	Specialty Care Center - Lima - Nephrology at SCL	967 Bellefontaine Avenue	Lima	OH	Terminated
PED363306-63	Child	PED	Dayton Children's Hospital	SPECIALTY CARE CENTER-WARREN CO - Nephrology Clinic	100 CAMPUS LOOP RD	MIDDLETOWN	OH	Terminated
PED363306-64	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGFIELD - Nephrology at PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-65	Child	PED	Dayton Children's Hospital	SPECIALTY CARE CENTER-WARREN CO - Endocrinology Clinic	100 CAMPUS LOOP RD	MIDDLETOWN	OH	Terminated
PED363306-66	Child	PED	Dayton Children's Hospital	Specialty Care Center - Lima - Neurology at SCL	967 Bellefontaine Avenue	Lima	OH	Terminated
PED363306-67	Child	PED	Dayton Children's Hospital	Specialty Care Center - Lima - Neurology Lab at SCL	967 Bellefontaine Avenue	Lima	OH	Terminated
PED363306-68	Child	PED	Dayton Children's Hospital	SPECIALTY CARE CENTER-WARREN CO - Pulmonary Clinic	100 CAMPUS LOOP RD	MIDDLETOWN	OH	Terminated
PED363306-69	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springfield - Pulm Diag Lab at PCAS	1644 North Limestone Street	Springfield	OH	Active
PED363306-70	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGFIELD - Pulmonary at PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-71	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGFIELD - Gastroent at PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-72	Child	PED	Dayton Children's Hospital	SPECIALTY CARE CENTER-WARREN CO - Gastroenterology Clinic	100 CAMPUS LOOP RD	MIDDLETOWN	OH	Terminated
PED363306-73	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Springboro - Ortho Rehab at OCCS	3333 West Tech Road	Miamisburg	OH	Active
PED363306-74	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGSBORO - Orthopaedic Clin OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-75	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGSBORO - Phys Med at OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-76	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGBORO - AYA at OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Terminated
PED363306-77	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGBORO - Urololgy at OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-78	Child	PED	Dayton Children's Hospital	SPECIALTY CARE CENTER-WARREN CO - Allergy Clinic	100 CAMPUS LOOP RD	MIDDLETOWN	OH	Terminated
PED363306-79	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGFIELD - Neurology Lab at PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-80	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER-SPRINGSBORO - Physical Therapy	3333 W TECH BLVD	MIAMISBURG	OH	Terminated
PED363306-81	Child	PED	Dayton Children's Hospital	SPECIALTY CARE CENTER-WARREN CO - Hematology Clinic	100 CAMPUS LOOP RD	MIDDLETOWN	OH	Terminated
PED363306-82	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGFIELD - Cardio Testing at PCAS	1644 N LIMESTONE ST	SPRINGFIELD	OH	Active
PED363306-83	Child	PED	Dayton Children's Hospital	SPECIALTY CARE CENTER-WARREN CO - Sleep Clinic	100 CAMPUS LOOP RD	MIDDLETOWN	OH	Terminated
PED363306-84	Child	PED	Dayton Children's Hospital	SPECIALTY CARE CENTER-WARREN CO - Care Clinic	100 CAMPUS LOOP RD	MIDDLETOWN	OH	Terminated
PED363306-85	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGBORO - ASC discharge OCCS/ South Surgery Center/ SSC PACU/Phase II/ SSC Preop	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-87	Child	PED	Dayton Children's Hospital	CHILD HEALTH PAVILION - Psychiatry Clinic TCHP	1010 VALLEY ST	DAYTON	OH	Terminated
PED363306-88	Child	PED	Dayton Children's Hospital	CHILD HEALTH PAVILION - Healthy Me Cl at TCHP	1010 VALLEY ST	DAYTON	OH	Active
PED363306-89	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Huber Heights - Urgent Care at OCCHH	8501 OLD TROY PIKE	HUBER HEIGHTS	OH	Active
PED363306-90	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGBORO - Chronic Pain at OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-91	Child	PED	Dayton Children's Hospital	OUTPATIENT CARE CENTER - SPRINGBORO - Nephrology at OCCS	3333 W TECH BLVD	MIAMISBURG	OH	Active
PED363306-92	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Troy - Orthopaedic Clin OCCT	865 W MARKET ST	TROY	OH	Active
PED363306-93	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Troy - Diabetes at OCCT	865 W MARKET ST	TROY	OH	Active
PED363306-94	Child	PED	Dayton Children's Hospital	Outpatient Care Center - Troy - Cardio Clinic OCCT	865 W MARKET ST	TROY	OH	Active
PED363306-95	Child	PED	Dayton Children's Hospital	Behavioral Health Center - Psychology BHCenter	76 Remick Blvd	Springboro	OH	Active
PED363306-96	Child	PED	Dayton Children's Hospital	Behavioral Health Center - Psychiatry BHCenter	76 Remick Blvd	Springboro	OH	Active
PED363306-97	Child	PED	Dayton Children's Hospital	CHILD HEALTH PAVILION - Complex Care at TCHP	1010 VALLEY ST	DAYTON	OH	Active
PED363306-98	Child	PED	Dayton Children's Hospital	CHILD HEALTH PAVILION - Foster Care Cl at TCHP	1010 VALLEY ST	DAYTON	OH	Terminated
PED363306-99	Child	PED	Dayton Children's Hospital	CHILD HEALTH PAVILION - Dev Peds TCHP	1010 VALLEY ST	DAYTON	OH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 8:03:39 AM	8/29/2024 11:08:01 AM	8/29/2024 11:08 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0339776 (OH)		8/29/2023 8:03 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0799999 (OH)		8/29/2023 8:03 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0180849 (OH)		8/29/2023 8:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1730392309 (OH)		8/29/2023 8:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1487108932 (OH)		8/29/2023 8:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1669546081 (OH)		8/29/2023 8:03 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1255942868 (OH)		8/29/2023 8:03 AM
Details	Last Recertification Date	Update	Recertification	9/13/2022 7:51:29 AM	8/29/2023 8:03:39 AM	8/29/2023 8:03 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 7:53:38 AM	9/13/2022 7:51:29 AM	9/13/2022 7:51 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	465509 (OH)		9/10/2021 7:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2021 7:53 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0465509	9/10/2021 7:53 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/10/2021 7:53 AM
Details	Last Recertification Date	Update	Recertification	9/9/2020 7:52:30 AM	9/10/2021 7:53:38 AM	9/10/2021 7:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		465509	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0339776	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0799999	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		0180849	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	0465509 (OH)		9/9/2020 7:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1457379448	9/9/2020 7:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1730392309	9/9/2020 7:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1487108932	9/9/2020 7:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1669546081	9/9/2020 7:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1255942868	9/9/2020 7:52 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/9/2020 7:52 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1457379448 ( )		9/9/2020 7:52 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 4:13:46 PM	9/9/2020 7:52:30 AM	9/9/2020 7:52 AM
Details	Entity Subname	Update	Recertification	Outpatient Care Center Springboro -Healthy Me Clinic at OCCS	Outpatient Care Center - Springboro - Healthy Me CL at OCCS	9/9/2020 7:52 AM
Details	Last Recertification Date	Update	Recertification		8/21/2019 4:13:46 PM	8/21/2019 4:13 PM
Details	Entity Subname	Update	Change Request	Outpatient Care Center Springboro -Lipid Clinic - Lipid	Outpatient Care Center Springboro -Healthy Me Clinic at OCCS	4/16/2019 10:44 AM
Contacts	Primary Contact	Update	Change Request	Voorhies, John H Director of Pharmacy Dayton Children's Hospital 9376415290	Meyers, Chad Director of Ambulatory Pharmacy Services Dayton Children's 9376414591	12/13/2018 3:11 PM
Details	State	Update		Approved	Active	10/1/2018 12:05 AM
Contacts	Signed By	Insert	New Registration		Goodstein, Benjamin VICE PRESIDENT and Chief Ambulatory Officer Dayton Children's 9376413450	8/6/2018 3:16 PM
Details	340B ID	Update	New Registration		PED363306-20	8/6/2018 3:16 PM
Details	Entity Subname	Update	New Registration	Outpatient Care Center Springboro -Lipid Clinic	Outpatient Care Center Springboro -Lipid Clinic - Lipid	8/6/2018 3:16 PM
Dates	Participating Approval Date	Update	New Registration		8/6/2018 3:16:41 PM	8/6/2018 3:16 PM
Details	State	Update	New Registration	Pending	Approved	8/6/2018 3:16 PM
Dates	Signed By Date	Update	New Registration		7/12/2018 4:21:54 PM	8/6/2018 3:16 PM
Dates	Start Date	Update	New Registration		10/1/2018 12:00:00 AM	8/6/2018 3:16 PM
Addresses	Main Address	Insert	New Registration		3333 West Tech Road Miamisburg, OH 45342	7/12/2018 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/12/2018 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0465509	7/12/2018 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	7/12/2018 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457379448	7/12/2018 1:32 PM
Contacts	Authorizing Official	Insert	New Registration		Goodstein, Benjamin VICE PRESIDENT and Chief Ambulatory Officer Dayton Children's 9376413450	7/12/2018 1:32 PM
Contacts	Primary Contact	Insert	New Registration		Voorhies, John H Director of Pharmacy Dayton Children's Hospital 9376415290	7/12/2018 1:32 PM
Details	Last Recertification Date	Insert	New Registration			7/12/2018 1:32 PM
Details	Grant Number	Insert	New Registration			7/12/2018 1:32 PM
Details	340B ID	Insert	New Registration			7/12/2018 1:32 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/12/2018 1:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/12/2018 1:32 PM
Details	Medicare Provider Number	Insert	New Registration		363306	7/12/2018 1:32 PM
Details	Entity Name	Insert	New Registration		Dayton Children's Hospital	7/12/2018 1:32 PM
Details	Program Code	Insert	New Registration		PED	7/12/2018 1:32 PM
Details	Entity Subname	Insert	New Registration		Outpatient Care Center Springboro -Lipid Clinic	7/12/2018 1:32 PM
Dates	Participating Approval Date	Insert	New Registration			7/12/2018 1:32 PM
Details	State	Insert	New Registration		Pending	7/12/2018 1:32 PM
Dates	Registration Date	Insert	New Registration		7/12/2018 1:32:03 PM	7/12/2018 1:32 PM
Dates	Signed By Date	Insert	New Registration			7/12/2018 1:32 PM
Dates	Start Date	Insert	New Registration			7/12/2018 1:32 PM
Terminations	Termination Comments	Insert	New Registration			7/12/2018 1:32 PM
Terminations	Termination Date	Insert	New Registration			7/12/2018 1:32 PM
Terminations	Termination Effective Date	Insert	New Registration			7/12/2018 1:32 PM
Terminations	Termination Reason	Insert	New Registration			7/12/2018 1:32 PM