Covered Entity Details

RRC390001-05 COMMUNITY MEDICAL CENTER (Active) - information as of 5/1/2025 11:54:55 PM

Main Details

Name

COMMUNITY MEDICAL CENTER

Subdivision Name

GEISINGER COMMUNITY MEDICAL CENTER - MRI VIEWMONT

Type

Rural Referral Center

Rural

Yes

340B ID

RRC390001-05

Medicare Provider Number

390001

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/9/2025

Participating Start Date

4/1/2025

Participating Approval Date

2/28/2025

Last Recertification Date

Contacts

Authorizing Official

Geisinger Wyoming Valley Medical Center
Ron Beer, Chief Admiistrative Officer
(570) 808-5380

Primary Contact

Geisinger Health
Lola Travelpiece, 340B Program Manager
(570) 214-1035

Addresses

Street Address

435 SCRANTON CARBONDALE HIGHWAY
SCRANTON, PA 18508-1115

Billing Address

Community Medical Center
1800 Mulberry St
Scranton, PA 18510

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
Participating from effective date: (07/01/2019) until terminated effective date: (04/01/2022); reinstatement effective date: (04/1/2025)	02/28/2025

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
PA	1007456760006,1007456760023,1007456760032,1007456760035,1007456760040,1007456760041	1366444507,1548648272,1770960130,1972652063,1245823764

Shipping Addresses

Shipping Address 1

Community Medical Center
1800 Mulberry St
Scranton, PA 18510

Shipping Address 2

GSS Distribution Center
212 Industrial Park Rd
Elysburg, PA 17824

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
RRC390001-01	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - GEN DIAGNOSTIC RAD VMT	435 SCRANTON CARBONDALE HIGHWAY	SCRANTON	PA	Terminated
RRC390001-02	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - CAT SCANNER VIEWMONT	435 SCRANTON CARBONDALE HIGHWAY	SCRANTON	PA	Active
RRC390001-03	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - MT PLEASANT RADIOLOGY	531 MT PLEASANT DRIVE	SCRANTON	PA	Terminated
RRC390001-04	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - OCCUP THERAPY OP VIEWMONT	423 SCRANTON-CARBONDALE HIGHWAY	SCRANTON	PA	Terminated
RRC390001-05	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - MRI VIEWMONT	435 SCRANTON CARBONDALE HIGHWAY	SCRANTON	PA	Active
RRC390001-06	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - MT PLEASANT MAMMOGRAPHY	531 MT PLEASANT DRIVE	SCRANTON	PA	Terminated
RRC390001-07	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - PHYSICAL THERAPY OP VIEWMONT	423 SCRANTON-CARBONDALE HIGHWAY	SCRANTON	PA	Terminated
RRC390001-08	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - ULTRASOUND VIEWMONT	435 SCRANTON CARBONDALE HIGHWAY	SCRANTON	PA	Terminated
RRC390001-09	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - NUCLEAR MEDICINE VMT	5 MORGAN HIGHWAY SUITE 7	SCRANTON	PA	Terminated
RRC390001-10	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - MAMMOGRAPHY VIEWMONT	435 SCRANTON CARBONDALE HIGHWAY	SCRANTON	PA	Terminated
RRC390001-11	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - MT PLEASANT ULTRASOUND	531 MT PLEASANT DRIVE	SCRANTON	PA	Terminated
RRC390001-12	Child	RRC	COMMUNITY MEDICAL CENTER	Neurology W. Olive St - Neurology	3 West Olive Street	Scranton	PA	Terminated
RRC390001-13	Child	RRC	COMMUNITY MEDICAL CENTER	Neurophysiology W. Olive St. - Neurophysiology	3 West Olive Street	Scranton	PA	Terminated
RRC390001-14	Child	RRC	COMMUNITY MEDICAL CENTER	Otolaryngology ACC W Olive St - Otolaryngology	3 West Olive Street	Scranton	PA	Terminated
RRC390001-15	Child	RRC	COMMUNITY MEDICAL CENTER	Dermatology ACC W Olive St. - Dermatology	3 West Olive St	Scranton	PA	Terminated
RRC390001-16	Child	RRC	COMMUNITY MEDICAL CENTER	Endocrinology W. Olive St. - Endocrinology	3 West Olive Street	Scranton	PA	Terminated
RRC390001-17	Child	RRC	COMMUNITY MEDICAL CENTER	Gastroenterology ACC Olive St - Gastroenterology ACC Olive St.	3 West Olive St	Scranton	PA	Terminated
RRC390001-18	Child	RRC	COMMUNITY MEDICAL CENTER	Urogyn ACC W. Olive St - Urogyn	3 West Olive Street	Scranton	PA	Terminated
RRC390001-19	Child	RRC	COMMUNITY MEDICAL CENTER	Geisinger Community Medical Center - Audiology W Olive St	3 West Olive St	Scranton	PA	Terminated
RRC390001-20	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - PET Imaging Viewmont	5 Morgan Hwy	SCRANTON	PA	Active
RRC390001-21	Child	RRC	COMMUNITY MEDICAL CENTER	Geisinger Community Medical Center - GYN OB W Olive St	3 West Olive St	Scranton	PA	Terminated
RRC390001-22	Child	RRC	COMMUNITY MEDICAL CENTER	Geisinger Community Medical Center - OB US Imaging W Olive St	3 West Olive St	Scranton	PA	Terminated
RRC390001-23	Child	RRC	COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - XR Imaging Viewmont	435 SCRANTON CARBONDALE HWY	SCRANTON	PA	Active
RRC390001-26	Child	RRC	COMMUNITY MEDICAL CENTER	Geisinger Community Medical Center - GYN Urology W Olive St	3 West Olive St	Scranton	PA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	4/1/2025 12:01 AM
Addresses	Shipping Address	Update	Reinstatement	Community Medical Center Pharmacy 1822 Mulberry St Scranton, PA 18510	Community Medical Center 1800 Mulberry St Scranton, PA 18510	2/28/2025 2:30 PM
Addresses	Billing Address	Insert	Reinstatement		Community Medical Center 1800 Mulberry St Scranton, PA 18510	2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760005 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760020 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760031 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760036 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760037 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760033 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760034 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760038 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Delete	Reinstatement	1007456760039 (PA)		2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1007456760040	2/28/2025 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		PA	2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Reinstatement		False	2/28/2025 2:30 PM
Medicaid Billing	Medicaid: Number	Insert	Reinstatement		1007456760041	2/28/2025 2:30 PM
Medicaid Billing	Medicaid: State	Insert	Reinstatement		PA	2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1124405592 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1255540647 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1265495394 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1285032128 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1326446253 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1336526276 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1417334350 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1467850149 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1497132336 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Delete	Reinstatement	1689015489 (PA)		2/28/2025 2:30 PM
Medicaid Billing	NPI: Number	Insert	Reinstatement		1245823764	2/28/2025 2:30 PM
Medicaid Billing	NPI: State	Insert	Reinstatement		PA	2/28/2025 2:30 PM
Details	Last Recertification Date	Update	Reinstatement	9/1/2021 9:21:44 AM		2/28/2025 2:30 PM
Dates	Last Date That 340B Drugs Purchased	Update	Reinstatement	4/1/2022 12:00:00 AM		2/28/2025 2:30 PM
Dates	Participating Approval Date	Update	Reinstatement	4/16/2019 12:44:10 PM	2/28/2025 2:30:17 PM	2/28/2025 2:30 PM
Details	State	Update	Reinstatement	Terminated	Approved	2/28/2025 2:30 PM
Dates	Registration Date	Update	Reinstatement	4/4/2019 2:39:59 PM	1/9/2025 5:50:39 PM	2/28/2025 2:30 PM
Dates	Signed By Date	Update	Reinstatement	4/5/2019 6:22:25 PM	1/14/2025 8:50:32 AM	2/28/2025 2:30 PM
Dates	Start Date	Update	Reinstatement	7/1/2019 12:00:00 AM	4/1/2025 12:00:00 AM	2/28/2025 2:30 PM
Terminations	Termination Date	Update	Reinstatement	4/1/2022 12:00:00 AM		2/28/2025 2:30 PM
Terminations	Termination Effective Date	Update	Reinstatement	4/1/2022 12:00:00 AM		2/28/2025 2:30 PM
Terminations	Termination Reason	Update	Reinstatement	Change of covered entity type		2/28/2025 2:30 PM
Details	Comments Public	Insert	Reinstatement		Participating from effective date: (07/01/2019) until terminated effective date: (04/01/2022); reinstatement effective date: (04/1/2025)	2/28/2025 1:08 PM
Contacts	Primary Contact	Update	Profile Change Request	Travelpiece, Lola 340b Analyst Supervisor Geisinger Health 5702141035	Travelpiece, Lola 340B Program Manager Geisinger Health 5702141035	9/26/2022 9:58 AM
Details	State	Update		To Be Terminated	Terminated	4/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	3/14/2022 8:40 AM
Details	State	Update	Hospital Type Change Request	Active	To Be Terminated	3/14/2022 8:40 AM
Terminations	Termination Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	3/14/2022 8:40 AM
Terminations	Termination Effective Date	Update	Hospital Type Change Request		4/1/2022 12:00:00 AM	3/14/2022 8:40 AM
Terminations	Termination Reason	Update	Hospital Type Change Request		Change of covered entity type	3/14/2022 8:40 AM
Details	Last Recertification Date	Update	Recertification	8/17/2020 1:55:33 PM	9/1/2021 9:21:44 AM	9/1/2021 9:21 AM
Contacts	Primary Contact	Update	Change Request	Krah, Matthew Brandon 340B Program Manager Geisinger 5702140379	Travelpiece, Lola 340b Analyst Supervisor Geisinger Health 5702141035	12/21/2020 12:48 PM
Contacts	Primary Contact	Update	Profile Change Request	Krah, Matthew Brandon 340B Senior Pharmacy Analyst Geisinger 5702140379	Krah, Matthew Brandon 340B Program Manager Geisinger 5702140379	10/9/2020 3:27 PM
Addresses	Shipping Address	Insert	Change Request		GSS Distribution Center 212 Industrial Park Rd Elysburg, PA 17824	8/17/2020 2:03 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	100745676002 (PA)		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1366444507 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1255540647 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1972652063 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265495394 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1467850149 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1689015489 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1841547338 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1770960130 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1124405592 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1336526276 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1417334350 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1548648272 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1497132336 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1326446253 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1285032128 ( )		8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1124405592	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1255540647	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265495394	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1285032128	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1326446253	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1336526276	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366444507	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1417334350	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1467850149	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1497132336	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1548648272	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1689015489	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1770960130	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972652063	8/17/2020 1:55 PM
Medicaid Billing	NPI: State	Insert	Recertification		PA	8/17/2020 1:55 PM
Details	Last Recertification Date	Update	Recertification	8/22/2019 1:34:32 PM	8/17/2020 1:55:33 PM	8/17/2020 1:55 PM
Details	Last Recertification Date	Update	Recertification		8/22/2019 1:34:32 PM	8/22/2019 1:34 PM
Details	State	Update		Approved	Active	7/1/2019 12:05 AM
Addresses	Shipping Address	Insert	Change Request		Community Medical Center Pharmacy 1822 Mulberry St Scranton, PA 18510	6/3/2019 6:40 AM
Contacts	Signed By	Insert	New Registration		Beer, Ron Chief Admiistrative Officer Geisinger Wyoming Valley Medical Center 5708085380	4/16/2019 12:44 PM
Details	340B ID	Update	New Registration		RRC390001-05	4/16/2019 12:44 PM
Details	Entity Subname	Update	New Registration	GEISINGER COMMUNITY MEDICAL CENTER	GEISINGER COMMUNITY MEDICAL CENTER - MRI VIEWMONT	4/16/2019 12:44 PM
Dates	Participating Approval Date	Update	New Registration		4/16/2019 12:44:10 PM	4/16/2019 12:44 PM
Details	State	Update	New Registration	Pending	Approved	4/16/2019 12:44 PM
Dates	Signed By Date	Update	New Registration		4/5/2019 6:22:25 PM	4/16/2019 12:44 PM
Dates	Start Date	Update	New Registration		7/1/2019 12:00:00 AM	4/16/2019 12:44 PM
Addresses	Main Address	Insert	New Registration		435 SCRANTON CARBONDALE HIGHWAY SCRANTON, PA 18508-1115	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760006	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760005	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760023	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760020	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760031	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100745676002	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760032	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760036	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760037	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760033	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760035	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760034	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760038	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007456760039	4/4/2019 2:39 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1366444507	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1255540647	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1972652063	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1265495394	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1467850149	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1689015489	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1841547338	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1770960130	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1124405592	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1336526276	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1417334350	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1548648272	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1497132336	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1326446253	4/4/2019 2:39 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1285032128	4/4/2019 2:39 PM
Contacts	Authorizing Official	Insert	New Registration		Beer, Ron Chief Admiistrative Officer Geisinger Wyoming Valley Medical Center 5708085380	4/4/2019 2:39 PM
Contacts	Primary Contact	Insert	New Registration		Krah, Matthew Brandon 340B Senior Pharmacy Analyst Geisinger 5702140379	4/4/2019 2:39 PM
Details	Last Recertification Date	Insert	New Registration			4/4/2019 2:39 PM
Details	Grant Number	Insert	New Registration			4/4/2019 2:39 PM
Details	340B ID	Insert	New Registration			4/4/2019 2:39 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/4/2019 2:39 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/4/2019 2:39 PM
Details	Medicare Provider Number	Insert	New Registration		390001	4/4/2019 2:39 PM
Details	Entity Name	Insert	New Registration		COMMUNITY MEDICAL CENTER	4/4/2019 2:39 PM
Details	Program Code	Insert	New Registration		RRC	4/4/2019 2:39 PM
Details	Entity Subname	Insert	New Registration		GEISINGER COMMUNITY MEDICAL CENTER	4/4/2019 2:39 PM
Dates	Participating Approval Date	Insert	New Registration			4/4/2019 2:39 PM
Details	State	Insert	New Registration		Pending	4/4/2019 2:39 PM
Dates	Registration Date	Insert	New Registration		4/4/2019 2:39:59 PM	4/4/2019 2:39 PM
Dates	Signed By Date	Insert	New Registration			4/4/2019 2:39 PM
Dates	Start Date	Insert	New Registration			4/4/2019 2:39 PM
Terminations	Termination Comments	Insert	New Registration			4/4/2019 2:39 PM
Terminations	Termination Date	Insert	New Registration			4/4/2019 2:39 PM
Terminations	Termination Effective Date	Insert	New Registration			4/4/2019 2:39 PM
Terminations	Termination Reason	Insert	New Registration			4/4/2019 2:39 PM