Covered Entity Details

CH04898AB Lewis County Primary Care Center, Inc (Active) - information as of 5/4/2025 11:58:50 PM

Main Details

Name

Lewis County Primary Care Center, Inc

Subdivision Name

Maysville OB/GYN Family Health Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-030142

340B ID

CH04898AB

Grant Number

H80CS00106

Additional Details

Current Program Status

Active

Registration Date

1/2/2020

Participating Start Date

4/1/2020

Participating Approval Date

1/30/2020

Last Recertification Date

2/28/2025

Contacts

Authorizing Official

Lewis County Primary Care Center, Inc.
JERRY UGRIN, CEO
(606) 796-3029

Primary Contact

Lewis County Primary Care Center, Inc.
Chad Evans, PharmD
(606) 956-0188

Addresses

Street Address

910 Kenton Station Dr
Maysville, KY 41056-9613

Billing Address

Lewis County Primary Care Center, Inc.
P.O. Box 550
Vanceburg, KY 41179

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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
KY	31000268	1457303802
OH	0864613	1457303802

Shipping Addresses

Shipping Address 1

Maysville Primary Plus Pack Pharmacy
910 Kenton Station Drive
Maysville, KY 41056

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.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	Address Cont.	City	State
CH048980	Active	BPS-H80-001194	LEWIS COUNTY PRIMARY CARE CENTER, INC.	Lewis County Primary Care Center, Inc.	211 KY 59	Building A	VANCEBURG	KY
CH04898AA	Active	BPS-H80-001900	LEWIS COUNTY PRIMARY CARE CENTER, INC	ELEANOR JOHNSON'S WOMENS CENTER	211 Ky 59 BLDG C		Vanceburg	KY
CH04898AB	Active	BPS-H80-030142	Lewis County Primary Care Center, Inc	Maysville OB/GYN Family Health Center	910 Kenton Station Dr		Maysville	KY
CH04898AC	Active	BPS-H80-030528	Lewis County Primary Care Center, Inc	PrimaryPlus - Kid Care	1350 Medical Park Dr		Maysville	KY
CH04898AD	Active	BPS-H80-032336	Lewis County Primary Care Center, Inc	PrimaryPlus - Grayson	645 Interstate Dr		Grayson	KY
CH04898AE	Active	BPS-H80-030168	Lewis County Primary Care Center, Inc	Ripley School-based Health Center	502 S 2nd St		Ripley	OH
CH04898AF	Active	BPS-H80-032032	Lewis County Primary Care Center, Inc	PrimaryPlus - Denham Clinic	525 Tucker Dr		Maysville	KY
CH04898AG	Active	BPS-H80-034439	Lewis County Primary Care Center, Inc	Robertson County Family Health Center	45 Mcdowell St		Mount Olivet	KY
CH04898AH	Active	BPS-H80-035749	LEWIS COUNTY PRIMARY CARE CENTER INC	Bracken County School- based Center	106 Howell Dr		Brooksville	KY
CH04898AJ	Active	BPS-H80-033894	LEWIS COUNTY PRIMARY CARE CENTER INC	PrimaryPlus - Morehead	2300 KY-801		Morehead	KY
CH04898AK	Active	BPS-H80-038420	LEWIS COUNTY PRIMARY CARE CENTER INC	PrimaryPlus Mobile Unit	211 Ky 59 BLDG A		Vanceburg	KY
CH04898AL	Active	BPS-H80-038811	LEWIS COUNTY PRIMARY CARE CENTER INC	PrimaryPlus Medical Specialties & Residency	1 W McDonald Pkwy		Maysville	KY
CH04898C	Active	BPS-H80-001838	LEWIS COUNTY PRIMARY CARE CENTER, INC	Tollesboro Family Health Center & Clinic Pharmacy	17521 W Ky 9		TOLLESBORO	KY
CH04898E	Active	BPS-H80-004407	LEWIS COUNTY PRIMARY CARE CENTER, INC	FLEMINGBURG COUNTY FAMILY H.C	520 Elizaville Ave		Flemingsburg	KY
CH04898V	Active	BPS-H80-005115	LEWIS COUNTY PRIMARY CARE CENTER, INC	MAYSVILLE OB/GYN FAMILY HLTH	927 Kenton Station Dr		Maysville	KY
CH04898W	Active	BPS-H80-008511	LEWIS COUNTY PRIMARY CARE CENTER, INC	Bracken County Family Health Center	1551 Augusta Chatham Rd		Augusta	KY
CH04898X	Active	BPS-H80-010652	LEWIS COUNTY PRIMARY CARE CENTER, INC.	South Shore Family Health Center	142 Depot Drive		South Shore	KY
CH04898Y	Active	BPS-H80-027215	LEWIS COUNTY PRIMARY CARE CENTER, INC.	Ashland Family Health Center	432 16th Street		ASHLAND	KY
CH04898Z	Active	BPS-H80-002991	LEWIS COUNTY PRIMARY CARE CENTER, INC	LEWIS CO FAMILY DENTAL CLINIC	211 Ky 59 BLDG D		Vanceburg	KY

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH048980	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/01/2019
CH048980	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/01/2019	05/31/2023
CH048980	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/01/2024
CH048980	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/01/2024
CH048980	BERRY PHARMACIST GROUP, LLC.	MASON FAMILY DRUG	912 KENTON STATION DR	MAYSVILLE	KY	41056-9658	07/01/2019
CH048980	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/01/2024
CH048980	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/01/2024
CH048980	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	10/01/2024
CH048980	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/01/2021
CH048980	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/01/2021
CH048980	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/01/2021
CH048980	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/01/2021
CH048980	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/01/2021
CH048980	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/01/2021
CH048980	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/01/2021
CH048980	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/01/2021
CH048980	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/01/2021
CH048980	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/01/2021
CH048980	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/01/2021
CH048980	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/01/2021
CH048980	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/01/2021
CH048980	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2018
CH048980	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/01/2019
CH048980	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/01/2019
CH048980	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/01/2019
CH048980	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/01/2019
CH048980	GENOA HEALTHCARE LLC	1351 NEWTOWN PIKE	BUILDING 5	LEXINGTON	KY	40511-1282	10/01/2024
CH048980	KENTUCKY CENTRAL FILL FACILITY, L-010	5594 SHEPHERDSVILLE ROAD		LOUISVILLE	KY	40228-1012	01/01/2020	01/02/2020
CH048980	KENTUCKY CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06347	1221 LEXINGTON AVENUE	ASHLAND	KY	41101	04/01/2021
CH048980	KENTUCKY CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02380	2409 ARGILLITE ROAD	FLATWOODS	KY	41139	04/01/2021
CH048980	KENTUCKY CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05437	1157 RIDGEWAY AVENUE	FALMOUTH	KY	41040	10/01/2021
CH048980	KENTUCKY CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03016	101 LACY LANE	PARIS	KY	40361	10/01/2021
CH048980	KENTUCKY CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06337	1201 INDIAN MOUND DRIVE	MOUNT STERLING	KY	40353	04/01/2022
CH048980	KROGER COLUMBUS CENTRAL FILL #019	2270 RICKENBACKER PKWY W		COLUMBUS	OH	43217	10/01/2016	01/30/2023
CH048980	KROGER PHARMACY #014420	381 MARKET SQUARE DRIVE		MAYSVILLE	KY	41056	07/01/2014	01/30/2023
CH048980	KROGER PHARMACY 014-410	375 CROSSROADS BLVD.		COLD SPRING	KY	41076	07/01/2019	01/30/2023
CH048980	KROGER PHARMACY L734	300 KROGER CENTER		MOREHEAD	KY	40351	07/01/2019	01/30/2023
CH048980	KROGER PHARMACY N-575	811 GAY STREET		PORTSMOUTH	OH	45662	10/01/2016	01/30/2023
CH048980	MED-SAVE 2 LLC	D/B/A MED-SAVE GRAYSON	601 N CAROL MALONE BLVD SUITE-A	GRAYSON	KY	41143	10/01/2020
CH048980	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03416	802 11TH ST	PORTSMOUTH	OH	45662	10/01/2017
CH048980	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 07777	2812 SCIOTO TRAIL	PORTSMOUTH	OH	45662	10/01/2017
CH048980	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03498	4207 GALLIA ST.	NEW BOSTON	OH	45662	04/01/2021
CH048980	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 05429	521 EAST STATE STREET	GEORGETOWN	OH	45121	04/01/2021
CH048980	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 03474	320 JEFFERSON STREET	IRONTON	OH	45638	10/01/2021
CH048980	OHIO CVS STORES, L.L.C.	DBA: CVS/PHARMACY # 06349	1109 IRONTON HILLS DR.	IRONTON	OH	45638	07/01/2022
CH048980	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	10/01/2024
CH048980	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	10/01/2024
CH048980	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/01/2024
CH048980	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	10/01/2024
CH048980	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/01/2024
CH048980	OSMAN PHARMACY	MEGAL INVESTMENTS LLC	89 SECOND ST	VANCEBURG	KY	41179-5439	07/01/2019
CH048980	OWEN PHARMACIST GROUP	D/B/A MED-SAVE CARTER	261 W. TOM T. HALL BLVD. P.O. BOX 717	OLIVE HILL	KY	41164	10/01/2020	04/08/2024
CH048980	PREMIER PHARMACY SERVICES	410 CLOVERLEAF DR		BALDWIN PARK	CA	91706	01/01/2019	05/01/2022
CH048980	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/01/2018	10/01/2022
CH048980	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/01/2021
CH048980	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	10/01/2021
CH048980	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/01/2021
CH048980	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/01/2021
CH048980	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2751	426 S. HENDERSON STREET	FORT WORTH	TX	76104	04/01/2024
CH048980	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #11338	10160 INTERNATIONAL BLVD.	WEST CHESTER	OH	45246	04/01/2024
CH048980	RITE AID OF KENTUCKY, INC.	RITE AID #3920	1160 US HIGHWAY 68	MAYSVILLE	KY	41056	07/01/2014	02/01/2018
CH048980	ST. MATTHEWS SPECIALTY PHARMACY	DBA ST. MATTHEWS SPECIALTY PHARMACY	200 N HURSTBOURNE PKWY STE 176	LOUISVILLE	KY	40222	01/01/2023
CH048980	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2017
CH048980	WAL-MART PHARMACY #10-1139	200 WAL-MART WAY		MOREHEAD	KY	40351	01/01/2019
CH048980	WAL-MART PHARMACY 10-1368	11217 STATE ROUTE 41		WEST UNION	OH	45693	01/01/2019
CH048980	WAL-MART PHARMACY 10-1564	4490 GALLIA STREET		NEW BOSTON	OH	45662	01/01/2019
CH048980	WAL-MART PHARMACY 10-1569	240 WAL-MART WAY		MAYSVILLE	KY	41056	07/01/2014
CH048980	WAL-MART PHARMACY 10-1961	6711 ALEXANDRIA PIKE		ALEXANDRIA	KY	41001	01/01/2019	04/04/2024
CH048980	WAL-MART PHARMACY 10-2638	12504 U.S. 60		ASHLAND	KY	41102	10/01/2020
CH048980	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2017
CH048980	WALGREEN CO.	WALGREENS #17366	1160 US HIGHWAY 68	MAYSVILLE	KY	41056	02/13/2018
CH048980	WALGREEN CO.	WALGREENS #19810	3501 COURT ST	CATLETTSBURG	KY	41129	01/01/2019	02/23/2023
CH048980	WALGREEN CO.	WALGREENS #19356	933 BLACKBURN AVE	ASHLAND	KY	41101	01/01/2019
CH048980	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21170	393 WALLER AVE STE 5	LEXINGTON	KY	40504	04/01/2019
CH048980	WALGREEN CO.	WALGREENS #18010	380 W MAIN ST	MOREHEAD	KY	40351	07/01/2019
CH048980	WALGREEN CO.	WALGREENS #19751	410 W TOM T HALL BLVD	OLIVE HILL	KY	41164	07/01/2019	02/20/2025
CH048980	WALGREEN CO.	WALGREENS #19971	100 S CAROL MALONE BLVD	GRAYSON	KY	41143	10/01/2020
CH048980	WALGREEN CO.	WALGREENS #17727	1900 ARGILLITE RD	FLATWOODS	KY	41139	04/01/2024
CH048980	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	01/01/2024
CH048980	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2018
CH048980	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/01/2018
CH048980	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2018
CH048980	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	04/01/2018	10/01/2021
CH048980	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2024
CH048980	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	07/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/12/2024 2:54:30 PM	2/28/2025 3:36:42 PM	2/28/2025 3:36 PM
Details	Last Recertification Date	Update	Recertification	2/6/2023 2:50:02 PM	2/12/2024 2:54:30 PM	2/12/2024 2:54 PM
Details	Last Recertification Date	Update	Recertification	2/10/2022 1:48:05 PM	2/6/2023 2:50:02 PM	2/6/2023 2:50 PM
Addresses	Billing Address	Update	Recertification	Lewis County Primary Care Center, Inc. 211 KY 59 P.O. Box 55 Vanceburg, KY 41179	Lewis County Primary Care Center, Inc. P.O. Box 550 Vanceburg, KY 41179	2/10/2022 1:48 PM
Details	Last Recertification Date	Update	Recertification	2/18/2021 3:52:06 PM	2/10/2022 1:48:05 PM	2/10/2022 1:48 PM
Addresses	Shipping Address	Insert	Change Request		Maysville Primary Plus Pack Pharmacy 910 Kenton Station Drive Maysville, KY 41056	3/16/2021 6:46 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1457303802 ( )		2/18/2021 3:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457303802	2/18/2021 3:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		OH	2/18/2021 3:52 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457303802	2/18/2021 3:52 PM
Medicaid Billing	NPI: State	Insert	Recertification		KY	2/18/2021 3:52 PM
Details	Last Recertification Date	Update	Recertification		2/18/2021 3:52:06 PM	2/18/2021 3:52 PM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		UGRIN, JERRY CEO Lewis County Primary Care Center, Inc. 6067963029	1/30/2020 1:26 PM
Details	340B ID	Update	New Registration		CH04898AB	1/30/2020 1:26 PM
Dates	Participating Approval Date	Update	New Registration		1/30/2020 1:26:23 PM	1/30/2020 1:26 PM
Details	State	Update	New Registration	Pending	Approved	1/30/2020 1:26 PM
Dates	Signed By Date	Update	New Registration		1/3/2020 1:25:57 PM	1/30/2020 1:26 PM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	1/30/2020 1:26 PM
Addresses	Main Address	Insert	New Registration		910 Kenton Station Dr Maysville, KY 41056-9613	1/2/2020 4:58 PM
Addresses	Billing Address	Insert	New Registration		Lewis County Primary Care Center, Inc. 211 KY 59 P.O. Box 55 Vanceburg, KY 41179	1/2/2020 4:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/2/2020 4:58 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		31000268	1/2/2020 4:58 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		KY	1/2/2020 4:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/2/2020 4:58 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		0864613	1/2/2020 4:58 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	1/2/2020 4:58 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1457303802	1/2/2020 4:58 PM
Contacts	Primary Contact	Insert	New Registration		Evans, Chad PharmD Lewis County Primary Care Center, Inc. 6069560188	1/2/2020 4:58 PM
Contacts	Authorizing Official	Insert	New Registration		UGRIN, JERRY CEO Lewis County Primary Care Center, Inc. 6067963029	1/2/2020 4:58 PM
Details	Last Recertification Date	Insert	New Registration			1/2/2020 4:58 PM
Details	Grant Number	Insert	New Registration		H80CS00106	1/2/2020 4:58 PM
Details	340B ID	Insert	New Registration			1/2/2020 4:58 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/2/2020 4:58 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/2/2020 4:58 PM
Details	Medicare Provider Number	Insert	New Registration			1/2/2020 4:58 PM
Details	Entity Name	Insert	New Registration		Lewis County Primary Care Center, Inc	1/2/2020 4:58 PM
Details	Program Code	Insert	New Registration		CH	1/2/2020 4:58 PM
Details	Entity Subname	Insert	New Registration		Maysville OB/GYN Family Health Center	1/2/2020 4:58 PM
Dates	Participating Approval Date	Insert	New Registration			1/2/2020 4:58 PM
Details	State	Insert	New Registration		Pending	1/2/2020 4:58 PM
Dates	Registration Date	Insert	New Registration		1/2/2020 4:58:34 PM	1/2/2020 4:58 PM
Dates	Signed By Date	Insert	New Registration			1/2/2020 4:58 PM
Dates	Start Date	Insert	New Registration			1/2/2020 4:58 PM
Terminations	Termination Comments	Insert	New Registration			1/2/2020 4:58 PM
Terminations	Termination Date	Insert	New Registration			1/2/2020 4:58 PM
Terminations	Termination Effective Date	Insert	New Registration			1/2/2020 4:58 PM
Terminations	Termination Reason	Insert	New Registration			1/2/2020 4:58 PM

340B Drug Pricing Program Database