Covered Entity Details

RRC340014-22 FORSYTH MEMORIAL HOSPITAL INC (Terminated) - information as of 4/29/2025 1:41:15 AM

Main Details

Name

FORSYTH MEMORIAL HOSPITAL INC

Subdivision Name

Novant Health Cancer Institute-Forsyth

Type

Rural Referral Center

Rural

Yes

340B ID

RRC340014-22

Medicare Provider Number

340014

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/7/2020

Participating Start Date

7/8/2020

Participating Approval Date

7/8/2020

Last Recertification Date

8/30/2021

Termination Date
Termination Reason

10/1/2022
Business decision by the Covered Entity

Contacts

Authorizing Official

Novant Health
Geoffrey Gardner, SVP Finance
(336) 718-2078

Primary Contact

Novant Health
Elizabeth Anne Corazzo, Manager Pharmacy 340B
(336) 277-0301

Addresses

Street Address

3333 SILAS CREEK PARKWAY
WINSTON-SALEM, NC 27103

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
FL	096065900
NC		1447200233,1881961662
VA		1447200233,1881961662
SC		1447200233,1881961662

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
RRC340014-01	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Occupational Therapy - Occupational Therapy	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-02	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Anesthesiology - Anesthesia	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-03	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Occupational Therapy - Occupational Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-04	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH WEST FORSYTH INTERNAL - Internal Medicine & Pediatrics	105 STADIUM OAKS DRIVE	CLEMMONS	NC	Active
RRC340014-05	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Operating Room - Surgical	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-06	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Radiology - Radiology	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-07	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Clinical Laboratory - Clinical Lab	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-08	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Orthopedic Outpatient Surgery - Orthopedic Surgery	180 Kimel Park Drive	Winston-Salem	NC	Active
RRC340014-09	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Emergency - Emergency	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-10	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Cardiac Non-Invasive Lab - Cardiology	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-11	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH RHEUMATOLOGY AND ARTH - Rheumatology	291 BROAD ST	KERNERSVILLE	NC	Active
RRC340014-12	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH UROLOGY - Urology	140 KIMEL PARK DRIVE SUITE 100	WINSTON SALEM	NC	Active
RRC340014-13	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH FORSYTH INTERNAL MEDI - Internal Medicine	1381 WESTGATE CENTER DR	WINSTON SALEM	NC	Active
RRC340014-14	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH ARCADIA FAMILY MEDICI - Family Medicine	12208 HIGHWAY 150 NORTH	WINSTON SALEM	NC	Active
RRC340014-15	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH UROLOGY - Urology	2010 BALDWIN LN	WINSTON SALEM	NC	Active
RRC340014-16	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health WSHC Convenient Care Clinic - General Medicine	250 CHARLOIS BLVD	WINSTON SALEM	NC	Terminated
RRC340014-17	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH CARDIOLOGY KERNERSVIL - Cardiology	1710 KERNERSVILLE MEDICAL PKWY	KERNERSVILLE	NC	Active
RRC340014-18	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Cancer Institute - Kernersville	1710 KERNERSVILLE MEDICAL PKWY	KERNERSVILLE	NC	Terminated
RRC340014-19	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Forsyth Endocrine - Thomasville - Endocrinology	903 Randolph Street	Thomasville	NC	Active
RRC340014-20	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH MAPLEWOOD FAMILY MEDI - Family Medicine	ROBINHOOD MEDICAL PLAZA	WINSTON-SALEM	NC	Active
RRC340014-21	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH PFAFFTOWN FAMILY MEDI - Family Medicine	4611 YADKINVILLE ROAD	PFAFFTOWN	NC	Active
RRC340014-22	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Cancer Institute-Forsyth	3333 SILAS CREEK PARKWAY	WINSTON-SALEM	NC	Terminated
RRC340014-23	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Cancer Institute - Thomasville	1213 LEXINGTON AVE	THOMASVILLE	NC	Terminated
RRC340014-24	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH THOMASVILLE MEDICAL A - General Medicine	309 PINEYWOOD RD	THOMASVILLE	NC	Active
RRC340014-25	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Osteoporosis Clinic - Osteoporosis	6915 Village Medical Circle	Clemmons	NC	Active
RRC340014-26	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH FORSYTH ENDOCRINE CON - Endocrinology	755 HIGHLAND OAKS DRIVE,	WINSTON SALEM	NC	Active
RRC340014-27	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH WOUND CARE - Wound Care	1710 KERNERSVILLE MEDICAL PKWY	KERNERSVILLE	NC	ToBeTerminated
RRC340014-28	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Cancer Institute - Statesville	276 OLD MOCKSVILLE ROAD	STATESVILLE	NC	Terminated
RRC340014-29	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH DAVIE MEDICAL ASSOCIA - General Medicine	485 VALLEY RD	MOCKSVILLE	NC	Active
RRC340014-30	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health WSHC Coumadin Clinic - Anticoagulation	250 CHARLOIS BLVD	WINSTON SALEM	NC	Active
RRC340014-31	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH LEXINGTON PRIMARY CAR - General Medicine	110 WEST MEDICAL PARK DR	LEXINGTON	NC	Terminated
RRC340014-32	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH OSTEOPOROSIS CLINIC - OSTEOPOROSIS	1710 KERNERSVILLE MEDICAL PKWYSTE 201	KERNERSVILLE	NC	Active
RRC340014-33	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC CT Scan - CT Scan	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-34	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Ultrasound - Ultrasound	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-35	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH YADKIN MEDICAL ASSOCI - General Medicine	305 E LEE AVE	YADKINVILLE	NC	Active
RRC340014-36	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH SURRY MEDICAL ASSOCIA - General Medicine	865 WESTLAKE DRIVE	MOUNT AIRY	NC	Active
RRC340014-37	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH INFECTIOUS DISEASE SP - Infectious Disease	1381 WESTGATE CENTER DRIVE	WINSTON-SALEM	NC	Active
RRC340014-38	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Speech Therapy - Speech Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-39	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH SURRY MEDICAL ASSOCIATES (ROCKFO - General Medicine	2133 ROCKFORD STREET	MT AIRY	NC	Terminated
RRC340014-40	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH HAWTHORNE OUTPATIENT - Outpatient Surgery	1999 SOUTH HAWTHORNE ROAD	WINSTON-SALEM	NC	Active
RRC340014-41	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Anesthesiology - Anesthesia	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-42	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC PAV - Pre-Anesthesia Visit	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-43	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH LEWISVILLE FAMILY MED - Family Medicine	1225 LEWISVILLE CLEMMONS RD	LEWISVILLE	NC	Terminated
RRC340014-44	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH PREMIER MEDICAL ASSOC - General Medicine	3333 BROOKVIEW HILLS BOULEVARD,	WINSTON-SALEM	NC	Active
RRC340014-45	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH NORTH POINT MEDICAL A - General medicine	1995 BETHABARA ROAD	WINSTON SALEM	NC	Active
RRC340014-46	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH TRIAD ENDOCRINE - Endocrinology	500 PINEVIEW DRIVE	KERNERSVILLE	NC	Active
RRC340014-47	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Physical Therapy - Physical Therapy	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-48	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Respiratory Therapy - Respiratory Therapy	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-49	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Radiology - Radiology	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-50	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Emergency Room - Emergency	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-51	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH CHAIR CITY FAMILY MED - Family Medicine	903 RANDOLPH ST	THOMASVILLE	NC	Active
RRC340014-52	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Urology - Kernersville - Urology	1730 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-53	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Operating Room - Surgical	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-54	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Physical Therapy - Physical Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-55	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Cancer Institute - Mount Airy	1908 Caudle Drive	Mount Airy	NC	Active
RRC340014-56	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH SALEM FAMILY MEDICINE - Family Medicine	105 VEST MILL CIRCLE	WINSTON SALEM	NC	Active
RRC340014-57	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH MOUNTAINVIEW MEDICAL - General Medicine	216 MOORE RD	KING	NC	Active
RRC340014-58	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH PILOT MOUNTAIN MEDICA - General Medicine	207 MEDICAL STREET	PILOT MOUNTAIN	NC	Active
RRC340014-59	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH FORSYTH FAMILY MEDICI - Family Medicine	400 JONESTOWN RD	WINSTON-SALEM	NC	Active
RRC340014-60	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Outpatient Infusion - Infusion	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-61	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Recovery Room (PACU) - Surgical	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-62	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Ultrasound - Ultrasound	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-63	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Mammography - Mammography	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-64	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Respiratory Therapy - Respiratory Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-65	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH CLEMMONS FAMILY MEDIC - Family Medicine	6301 STADIUM DRIVE	CLEMMONS	NC	Terminated
RRC340014-66	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health WSHC Dermatology - Dermatology	175 Kimel Park Drive	Winston Salem	NC	Active
RRC340014-67	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH CARDIOLOGY WINSTON SA - Cardiology	186 KIMEL PARK DR	WINSTON SALEM	NC	Active
RRC340014-68	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH CARDIOLOGY MT AIRY - Cardiology	694 RIVERSIDE DR	MOUNT AIRY	NC	Active
RRC340014-69	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH PSYCHIATRIC MEDICINE - Psychiatry	309 PINEYWOOD ROAD	THOMASVILLE	NC	Active
RRC340014-70	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC PAV - Pre-Anesthsia Visit	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-71	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Speech Therapy - Speech Therapy	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-72	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Nuclear Medicine - Radiology	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-73	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC CT Scan - CT Scan	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-74	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Outpatient Infusion - Infusion	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-75	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH PSYCHIATRY - PSYCHIATRY	175 KIMEL PARK DR	WINSTON SALEM	NC	Active
RRC340014-76	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH KERNERSVILLE FAMILY M - Family Medicine	291 BROAD ST	KERNERSVILLE	NC	Active
RRC340014-77	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Rheumatology and Arthritis - Rheumatology	1995 Bethabara Road	Winston-Salem	NC	Terminated
RRC340014-78	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health WSHC Internal Medicine - Internal Medicine	250 CHARLOIS BLVD	WINSTON SALEM	NC	Active
RRC340014-79	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	Novant Health Wound Care and Hyperbaric Medicine - Hawthorne - Wound Care and Hyperbaric Medicine	1901 S. Hawthorne Rd	Winston-Salem	NC	ToBeTerminated
RRC340014-80	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NOVANT HEALTH CARDIOLOGY CLEMMONS - Cardiology	7114 VILLAGE MEDICAL CIR	CLEMMONS	NC	Active
RRC340014-81	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC Cardiac Non-Invasive Lab - Cardiology	6915 Village Medical Circle	Clemmons	NC	Active
RRC340014-82	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH CMC PACU - Surgical Recovery	6915 VILLAGE MEDICAL CIRCLE	CLEMMONS	NC	Active
RRC340014-83	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Mobile PET - Nuclear Medicine	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-84	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	KMC Endoscopy - Endoscopy	1750 Kernersville Medical Parkway	KERNERSVILLE	NC	Active
RRC340014-85	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH FORSYTH HEART AND WELLNESS COUMADIN CLINIC - ANTICOAGULATION CLINIC	3333 SILAS CREEK PARKWAY	WINSTON-SALEM	NC	Active
RRC340014-86	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH FORSYTH HEART AND WELLNESS HEART CLINIC - CARDIOLOGY	3333 SILAS CREEK PARKWAY	WINSTON-SALEM	NC	Active
RRC340014-87	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Neurodiagnostics - Neurology	1750 Kernersville Medical Pkwy	Kernersville	NC	Active
RRC340014-88	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH Cardiology - Kimel Park Annex - Cardiology	185 Kimel Park Drive	Winston-Salem	NC	Active
RRC340014-89	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH Adult PC Miller Street - Primary Care	50 Miller Street	Winston-Salem	NC	Active
RRC340014-90	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Cardiac Cath Lab - Heart Cath	1750 KERNERSVILLE MEDICAL PARKWAY	Kernersville	NC	Active
RRC340014-91	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Vascular Access Therapy Team - Vascular Therapy	1750 Kernersville Medical Parkway	Kernersville	NC	Active
RRC340014-92	Child	RRC	FORSYTH MEMORIAL HOSPITAL INC	NH KMC Cardiovascular Pre-Post - Cardiology	1750 Kernersville Parkway	Kernersville	NC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
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	State	Update		To Be Terminated	Terminated	10/1/2022 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		3/31/2022 12:00:00 AM	7/22/2022 2:20 PM
Details	State	Update	Termination Request	Active	To Be Terminated	7/22/2022 2:20 PM
Terminations	Termination Comments	Update	Termination Request		DRUGS ORDERED ON 3/30, USED ON 3/31 LAST DAY OF BUSINESS.	7/22/2022 2:20 PM
Terminations	Termination Date	Update	Termination Request		10/1/2022 12:00:00 AM	7/22/2022 2:20 PM
Terminations	Termination Effective Date	Update	Termination Request		3/31/2022 12:00:00 AM	7/22/2022 2:20 PM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	7/22/2022 2:20 PM
Details	Last Recertification Date	Update	Recertification	9/10/2020 9:00:06 AM	8/30/2021 3:26:42 PM	8/30/2021 3:26 PM
Details	Entity Subname	Update	Change Request	NOVANT HEALTH ONCOLOGY SPECIALISTS - Oncology	Novant Health Cancer Institute-Forsyth	10/19/2020 7:10 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/10/2020 9:00 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		096065900	9/10/2020 9:00 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/10/2020 9:00 AM
Medicaid Billing	NPI: State	Update	Recertification		NC	9/10/2020 9:00 AM
Medicaid Billing	NPI: State	Update	Recertification		NC	9/10/2020 9:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1447200233	9/10/2020 9:00 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/10/2020 9:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1881961662	9/10/2020 9:00 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/10/2020 9:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1447200233	9/10/2020 9:00 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/10/2020 9:00 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1881961662	9/10/2020 9:00 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/10/2020 9:00 AM
Details	Last Recertification Date	Update	Recertification		9/10/2020 9:00:06 AM	9/10/2020 9:00 AM
Details	State	Update	OPA Edit	Approved	Active	7/8/2020 2:07 PM
Dates	Start Date	Update	OPA Edit	10/1/2020 12:00:00 AM	7/8/2020 12:00:00 AM	7/8/2020 2:07 PM
Contacts	Signed By	Insert	New Registration		Gardner, Geoffrey SVP Finance Novant Health 3367182078	7/8/2020 2:03 PM
Details	340B ID	Update	New Registration		RRC340014-22	7/8/2020 2:03 PM
Details	Entity Subname	Update	New Registration	NOVANT HEALTH ONCOLOGY SPECIALISTS	NOVANT HEALTH ONCOLOGY SPECIALISTS - Oncology	7/8/2020 2:03 PM
Dates	Participating Approval Date	Update	New Registration		7/8/2020 2:03:07 PM	7/8/2020 2:03 PM
Details	State	Update	New Registration	Pending	Approved	7/8/2020 2:03 PM
Dates	Signed By Date	Update	New Registration		7/8/2020 9:13:59 AM	7/8/2020 2:03 PM
Dates	Start Date	Update	New Registration		10/1/2020 12:00:00 AM	7/8/2020 2:03 PM
Addresses	Main Address	Insert	New Registration		3333 SILAS CREEK PARKWAY WINSTON-SALEM, NC 27103	7/7/2020 12:35 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1447200233	7/7/2020 12:35 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1881961662	7/7/2020 12:35 PM
Contacts	Authorizing Official	Insert	New Registration		Gardner, Geoffrey SVP Finance Novant Health 3367182078	7/7/2020 12:35 PM
Contacts	Primary Contact	Insert	New Registration		Hansen, Elizabeth Corazzo Supervisor Pharmacy 340B Novant Health 3362770301	7/7/2020 12:35 PM
Details	Last Recertification Date	Insert	New Registration			7/7/2020 12:35 PM
Details	Grant Number	Insert	New Registration			7/7/2020 12:35 PM
Details	340B ID	Insert	New Registration			7/7/2020 12:35 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/7/2020 12:35 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/7/2020 12:35 PM
Details	Medicare Provider Number	Insert	New Registration		340014	7/7/2020 12:35 PM
Details	Entity Name	Insert	New Registration		FORSYTH MEMORIAL HOSPITAL INC	7/7/2020 12:35 PM
Details	Program Code	Insert	New Registration		RRC	7/7/2020 12:35 PM
Details	Entity Subname	Insert	New Registration		NOVANT HEALTH ONCOLOGY SPECIALISTS	7/7/2020 12:35 PM
Dates	Participating Approval Date	Insert	New Registration			7/7/2020 12:35 PM
Details	State	Insert	New Registration		Pending	7/7/2020 12:35 PM
Dates	Registration Date	Insert	New Registration		7/7/2020 12:35:30 PM	7/7/2020 12:35 PM
Dates	Signed By Date	Insert	New Registration			7/7/2020 12:35 PM
Dates	Start Date	Insert	New Registration			7/7/2020 12:35 PM
Terminations	Termination Comments	Insert	New Registration			7/7/2020 12:35 PM
Terminations	Termination Date	Insert	New Registration			7/7/2020 12:35 PM
Terminations	Termination Effective Date	Insert	New Registration			7/7/2020 12:35 PM
Terminations	Termination Reason	Insert	New Registration			7/7/2020 12:35 PM