| Details | Last Recertification Date | Update | Recertification | | 2/10/2025 8:06:04 AM | 2/10/2025 8:06 AM |
| Details | State | Update | | Approved | Active | 1/1/2025 12:01 AM |
| Addresses | Billing Address | Insert | Reinstatement | | Harbor Homes, Inc. Headquarters
77 Northeastern Blvd
Nashua, NH 03062 | 10/10/2024 8:51 AM |
| Contacts | Authorizing Official | Update | Reinstatement | Brown, Jonathan W
Clinic Director
Harbor Homes, Inc.
6034840722 | Belecz, William
Chief of Operations
Harbor Homes, Inc.
6038163106 | 10/10/2024 8:51 AM |
| Contacts | Signed By | Update | Reinstatement | Brown, Jonathan W
Clinic Director
Harbor Care Health & Wellness Center
6038167983 | Belecz, William
Chief of Operations
Harbor Homes, Inc.
6038163106 | 10/10/2024 8:51 AM |
| Contacts | Primary Contact | Update | Reinstatement | Gupta, Jay
Director of Pharmacy
Harbor Care Health and Wellness Center
6038166958-4021 | Avard, Chantal
Pharmacy Manager
Harbor Homes, Inc.
6038161966-4401 | 10/10/2024 8:51 AM |
| Details | Last Recertification Date | Update | Reinstatement | 2/10/2022 12:08:08 PM | | 10/10/2024 8:51 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Reinstatement | 4/1/2023 12:00:00 AM | | 10/10/2024 8:51 AM |
| Details | Entity Name | Update | Reinstatement | Harbor Homes, Inc. | HARBOR HOMES, INC. | 10/10/2024 8:51 AM |
| Details | Entity Subname | Update | Reinstatement | Harbor Care Health and Wellness Center | Harbor Care Clinic and Wellness Center | 10/10/2024 8:51 AM |
| Dates | Participating Approval Date | Update | Reinstatement | 1/10/2019 8:40:14 AM | 10/10/2024 8:51:47 AM | 10/10/2024 8:51 AM |
| Details | State | Update | Reinstatement | Terminated | Approved | 10/10/2024 8:51 AM |
| Dates | Registration Date | Update | Reinstatement | 1/2/2019 5:28:57 PM | 10/9/2024 8:42:09 AM | 10/10/2024 8:51 AM |
| Dates | Signed By Date | Update | Reinstatement | 1/9/2019 2:56:12 PM | 10/9/2024 8:42:12 AM | 10/10/2024 8:51 AM |
| Dates | Start Date | Update | Reinstatement | 4/1/2019 12:00:00 AM | 1/1/2025 12:00:00 AM | 10/10/2024 8:51 AM |
| Terminations | Termination Comments | Update | Reinstatement | Covered services are temporarily not provided at location. | | 10/10/2024 8:51 AM |
| Terminations | Termination Date | Update | Reinstatement | 4/1/2023 12:00:00 AM | | 10/10/2024 8:51 AM |
| Terminations | Termination Effective Date | Update | Reinstatement | 4/1/2023 12:00:00 AM | | 10/10/2024 8:51 AM |
| Terminations | Termination Reason | Update | Reinstatement | Business decision by the Covered Entity | | 10/10/2024 8:51 AM |
| Details | Comments Public | Insert | Reinstatement | | Participated starting 4/1/2019; Terminated 4/1/2023; Reinstated 1/1/2025. | 10/9/2024 2:24 PM |
| Details | State | Update | | To Be Terminated | Terminated | 4/1/2023 12:01 AM |
| Dates | Last Date That 340B Drugs Purchased | Update | Recertification | | 4/1/2023 12:00:00 AM | 2/15/2023 4:11 PM |
| Details | State | Update | Recertification | Active | To Be Terminated | 2/15/2023 4:11 PM |
| Terminations | Termination Comments | Update | Recertification | | Covered services are temporarily not provided at location. | 2/15/2023 4:11 PM |
| Terminations | Termination Date | Update | Recertification | | 4/1/2023 12:00:00 AM | 2/15/2023 4:11 PM |
| Terminations | Termination Effective Date | Update | Recertification | | 4/1/2023 12:00:00 AM | 2/15/2023 4:11 PM |
| Terminations | Termination Reason | Update | Recertification | | Business decision by the Covered Entity | 2/15/2023 4:11 PM |
| Addresses | Shipping Address | Delete | Recertification | Harbor Homes
45 High Street
Nashua, NH 03060 | | 2/10/2022 12:08 PM |
| Addresses | Billing Address | Update | Recertification | Harbor Homes
77 Northeastern Blvd
Nashua, NH 03062 | Harbor Homes, Inc. Headquarters
77 Northeastern Blvd
Nashua, NH 03062 | 2/10/2022 12:08 PM |
| Addresses | Shipping Address | Insert | Recertification | | Harbor Care Health and Wellness Center
45 High Street
Nashua, NH 03060 | 2/10/2022 12:08 PM |
| Details | Last Recertification Date | Update | Recertification | 2/10/2021 8:49:54 AM | 2/10/2022 12:08:08 PM | 2/10/2022 12:08 PM |
| Details | Entity Subname | Update | Recertification | Harbor Care Clinic and Wellness Center | Harbor Care Health and Wellness Center | 2/10/2022 12:08 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Brown, Jonathan W
Clinic Director
Harbor Care Health & Wellness Center
6038167983 | Brown, Jonathan W
Clinic Director
Harbor Homes, Inc.
6034840722 | 1/27/2022 12:21 PM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2020 9:08:03 AM | 2/10/2021 8:49:54 AM | 2/10/2021 8:49 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Gupta, Jay
Director of Pharmacy
Harbor Care Health and Wellness Center
6038161966 | Gupta, Jay
Director of Pharmacy
Harbor Care Health and Wellness Center
6038166958-4021 | 2/18/2020 10:48 AM |
| Details | Last Recertification Date | Update | Recertification | | 2/3/2020 9:08:03 AM | 2/3/2020 9:08 AM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 3108699 (NH) | | 10/4/2019 2:02 PM |
| Medicaid Billing | Medicaid: Number | Delete | Change Request | 3082687 (NH) | | 10/4/2019 2:02 PM |
| Medicaid Billing | NPI: Number | Delete | Change Request | 1699705079 ( ) | | 10/4/2019 2:02 PM |
| Details | State | Update | | Approved | Active | 4/1/2019 12:05 AM |
| Addresses | Billing Address | Insert | Change Request | | Harbor Homes
77 Northeastern Blvd
Nashua, NH 03062 | 1/18/2019 3:40 PM |
| Addresses | Shipping Address | Insert | Change Request | | Harbor Homes
45 High Street
Nashua, NH 03060 | 1/18/2019 3:40 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 1/18/2019 3:40 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 3108699 | 1/18/2019 3:40 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | NH | 1/18/2019 3:40 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 1/18/2019 3:40 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 3082687 | 1/18/2019 3:40 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | NH | 1/18/2019 3:40 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1699705079 | 1/18/2019 3:40 PM |
| Contacts | Signed By | Insert | New Registration | | Brown, Jonathan W
Clinic Director
Harbor Care Health & Wellness Center
6038167983 | 1/10/2019 8:40 AM |
| Details | 340B ID | Update | New Registration | | CHC12867-02 | 1/10/2019 8:40 AM |
| Dates | Participating Approval Date | Update | New Registration | | 1/10/2019 8:40:14 AM | 1/10/2019 8:40 AM |
| Details | State | Update | New Registration | Pending | Approved | 1/10/2019 8:40 AM |
| Dates | Signed By Date | Update | New Registration | | 1/9/2019 2:56:12 PM | 1/10/2019 8:40 AM |
| Dates | Start Date | Update | New Registration | | 4/1/2019 12:00:00 AM | 1/10/2019 8:40 AM |
| Addresses | Main Address | Insert | New Registration | |
615 Amherst St
Nashua, NH 03063-1052 | 1/2/2019 5:28 PM |
| Contacts | Primary Contact | Insert | New Registration | | Gupta, Jay
Director of Pharmacy
Harbor Care Health and Wellness Center
6038161966 | 1/2/2019 5:28 PM |
| Contacts | Authorizing Official | Insert | New Registration | | Brown, Jonathan W
Clinic Director
Harbor Care Health & Wellness Center
6038167983 | 1/2/2019 5:28 PM |
| Details | Last Recertification Date | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Details | Grant Number | Insert | New Registration | | H80CS12867 | 1/2/2019 5:28 PM |
| Details | 340B ID | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Details | Medicare Provider Number | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Details | Entity Name | Insert | New Registration | | Harbor Homes, Inc. | 1/2/2019 5:28 PM |
| Details | Program Code | Insert | New Registration | | CH | 1/2/2019 5:28 PM |
| Details | Entity Subname | Insert | New Registration | | Harbor Care Clinic and Wellness Center | 1/2/2019 5:28 PM |
| Dates | Participating Approval Date | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Details | State | Insert | New Registration | | Pending | 1/2/2019 5:28 PM |
| Dates | Registration Date | Insert | New Registration | | 1/2/2019 5:28:57 PM | 1/2/2019 5:28 PM |
| Dates | Signed By Date | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Dates | Start Date | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Terminations | Termination Comments | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Terminations | Termination Date | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 1/2/2019 5:28 PM |
| Terminations | Termination Reason | Insert | New Registration | | | 1/2/2019 5:28 PM |