Covered Entity Details

RRC390067-31 PINNACLE HEALTH HOSPITALS (Active) - information as of 4/27/2025 12:51:13 AM

Main Details

Name

PINNACLE HEALTH HOSPITALS

Subdivision Name

CGOH - Echo-CGH (34) - Echo

Type

Rural Referral Center

Rural

Yes

340B ID

RRC390067-31

Medicare Provider Number

390067

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/9/2021

Participating Start Date

7/1/2021

Participating Approval Date

5/6/2021

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

UPMC Central PA
Greg Mitstifer, CFO
(717) 231-8245

Primary Contact

UPMC Presbyterian Shadyside
William Zacharie Camp, 340B Manager
(740) 606-0376

Addresses

Street Address

4300 Londonderry Road
Harrisburg, PA 17109

Billing Address

UPMC Harrisburg Attn: Pharmacy
111 South Front Street
Harrisburg, PA 17101

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
PA	1000025630043,1000025630057,1000025630059,1000025630102,1000025630105,1000025630166,1000025630167,1000025630168,1000025630169,1000025630170,1000025630171,1000025630186,1000025630187,1000025630188,1000025630189,1000025630190,1000025630192,1000025630195,1000025630196,1000025630202,1000025630203,1000025630204,1000025630207,1000025630208,1000025630211,1000025630212,1000025630213,1000025630214,1000025630215	1164526588,1265537674,1346344769,1407813603,1922425651,1972613305,1255437638,1558731588

Shipping Addresses

Shipping Address 1

UPMC Pinnacle Community Osteopathic
4300 Londonderry Road
Harrisburg, PA 17109

Shipping Address 2

UPMC Pinnacle Harrisburg
111 South Front Street
Harrisburg, PA 17101

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
RRC390067-01	Child	RRC	PINNACLE HEALTH HOSPITALS	MSP - Med OP Onc Unit Med Ser (157) - Medical Outpatient Oncology Unit	4300 LONDONDERRY ROAD	HARRISBURG	PA	Active
RRC390067-02	Child	RRC	PINNACLE HEALTH HOSPITALS	ORTENZIO CANCER CENTER (53)	2020 TECHNOLOGY PARKWAY	MECHANICSBURG	PA	Active
RRC390067-03	Child	RRC	PINNACLE HEALTH HOSPITALS	Transplant Physicians-Gen Surg (654) - Transplant Physicians-Gen Surg (654)	205 South Front Street	Harrisburg	PA	Active
RRC390067-04	Child	RRC	PINNACLE HEALTH HOSPITALS	WS Anesthesia (2014) - WS Anesthesia	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-05	Child	RRC	PINNACLE HEALTH HOSPITALS	WS PACU (2013) - WS PACU	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-06	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Peri-Anesthesia Dept (412) - Peri-Anesthesia	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-07	Child	RRC	PINNACLE HEALTH HOSPITALS	WS Respiratory Therapy (2016) - WS Respiratory Therapy	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-08	Child	RRC	PINNACLE HEALTH HOSPITALS	Rad. Oncology - West Shore (51)	2035 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-09	Child	RRC	PINNACLE HEALTH HOSPITALS	WS Operating Room (2011) - WS Operating Room	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-10	Child	RRC	PINNACLE HEALTH HOSPITALS	WS Noninvasive Vascular (2029) - WS Noninvasive Vascular	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-11	Child	RRC	PINNACLE HEALTH HOSPITALS	WS Emergency Department (2010) - Emergency Department	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-12	Child	RRC	PINNACLE HEALTH HOSPITALS	WS ECHO (2023) - WS ECHO	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-13	Child	RRC	PINNACLE HEALTH HOSPITALS	Renal Transplant-Clinic (651) - Renal Transplant-Clinic	205 South Front Street	Harrisburg	PA	Active
RRC390067-15	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH Operating Room (411) - OR	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-16	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Endoscopy (632) - Endoscopy	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-17	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Respiratory Care (416) - Respiratory Care	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-18	Child	RRC	PINNACLE HEALTH HOSPITALS	FOC - Cardiology - FOHC (737) - Cardiology	2015 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-19	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Anesthesia (413) - Anesthesia	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-20	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Emergency Room CGH (421) - Emergency Department	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-21	Child	RRC	PINNACLE HEALTH HOSPITALS	MSP - Rad Oncology Med Serv Pav (52) - Radiation Oncology	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-22	Child	RRC	PINNACLE HEALTH HOSPITALS	BLM - Wound - East Shore Center (820) - Wound and Hyperbaric Center	4310 Londonberry Road	Harrisburg	PA	Active
RRC390067-23	Child	RRC	PINNACLE HEALTH HOSPITALS	FOC - Mammography PHH (887) - Mammography	2015 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-24	Child	RRC	PINNACLE HEALTH HOSPITALS	FOC - Pulmonary Diagnostic Lab-FOHC (174) - Pulmonology	2015 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-25	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - WS EKG (2024) - Cardiology	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-26	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - WS Cardiac & Vascular (2021) - Cardiac & Vascular	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-27	Child	RRC	PINNACLE HEALTH HOSPITALS	UPMC PINNACLE INFUSION CENTER - Hem/Onc Carlisle (328) - Oncology	2 Jennifer Court	Carlisle	PA	Active
RRC390067-28	Child	RRC	PINNACLE HEALTH HOSPITALS	UPMC PINNACLE INFUSION CENTER - Hem/Onc Lititz (327) - Oncology	1575 Highlands Drive	LITITZ	PA	Active
RRC390067-29	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - Cardiac Proces Unit (2032) - Cardiac Processing Unit	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-30	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - ED Obs Unit WSH (2041) - ED Observation	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-31	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Echo-CGH (34) - Echo	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-32	Child	RRC	PINNACLE HEALTH HOSPITALS	Oncology & Infusion in York (39910) - Oncology & Infusion	1703 Innovation Drive	York	PA	Active
RRC390067-33	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Pulmonary Function (172) - Pulmonary	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-34	Child	RRC	PINNACLE HEALTH HOSPITALS	FOC - Pain Management - Fred (639) - Pain Management Procedure Center	2005 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-35	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - EKG-CGH (417) - EKG	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-36	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - MRI PHH (885) - MRI	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-37	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Cardiac and Vascular (764) - Cardiac and Vascular	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-38	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - Ultrasound PHH (886) - Ultrasound	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-39	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - Ultrasound PHH (886) - Ultrasound	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-40	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - CT Scan PHH (884) - CT Scan	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-41	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - CT Scan PHH (884) - CT Scan	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-42	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - PHH - Nuclear Medicine (734) - Nuclear Medicine	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-43	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - PHH - Nuclear Medicine (734) - Nuclear Medicine	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-44	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - IP Diagnostic Radiology (731) - IP Diagnostic Radiology	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-45	Child	RRC	PINNACLE HEALTH HOSPITALS	CGOH - IP Diagnostic Radiology (731) - Diagnostic Radiology	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-46	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - PACU Overflow Unit (441) - PACU Overflow	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-47	Child	RRC	PINNACLE HEALTH HOSPITALS	CRL - Cardiovascular Carlisle (862) - Cardiovascular	360 Alexander Spring Road	Carlisle	PA	Active
RRC390067-48	Child	RRC	PINNACLE HEALTH HOSPITALS	LAC - Echo_Vascular - LVACC (877) - Cardiovascular	1251 East Main Street	Annville	PA	Active
RRC390067-49	Child	RRC	PINNACLE HEALTH HOSPITALS	LCV - Cardiovascular Old Post (860) - Cardiovascular	2808 Old Post Road	Harrisburg	PA	Active
RRC390067-50	Child	RRC	PINNACLE HEALTH HOSPITALS	MCV - Cardiovascular CenturyDr (880) - Cardiovascular	900 Century Drive	Mechanicsburg	PA	Active
RRC390067-51	Child	RRC	PINNACLE HEALTH HOSPITALS	NOC - Echo_Vascular - Newport (882) - Cardiovascular	300 Bretz Court	Newport	PA	Active
RRC390067-52	Child	RRC	PINNACLE HEALTH HOSPITALS	TUD - Echo Union Deposit (876) - Echo	4518 Union Deposit Road	Harrisburg	PA	Active
RRC390067-53	Child	RRC	PINNACLE HEALTH HOSPITALS	TPY - Cardiovascular Tech Pkwy (861) - Cardiovascular	2020 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-54	Child	RRC	PINNACLE HEALTH HOSPITALS	FOC - PHH - Nuclear Medicine (734) - Nuclear Medicine	2015 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-55	Child	RRC	PINNACLE HEALTH HOSPITALS	MSP - PHH - Nuclear Medicine (734) - Nuclear Medicine	4300 Londonderry Road	Harrisburg	PA	Active
RRC390067-56	Child	RRC	PINNACLE HEALTH HOSPITALS	CRL - PHH Cardiology (870) - Nuclear Medicine	360 Alexander Spring Road	Carlisle	PA	Active
RRC390067-57	Child	RRC	PINNACLE HEALTH HOSPITALS	TUD - PHH - Nuclear Medicine (734) - Nuclear Medicine	4518 Union Deposit Road	Harrisburg	PA	Active
RRC390067-58	Child	RRC	PINNACLE HEALTH HOSPITALS	NOC - PHH - Nuclear Medicine (734) - Nuclear Medicine	300 Bretz Court	Newport	PA	Active
RRC390067-59	Child	RRC	PINNACLE HEALTH HOSPITALS	LCV - PHH Cardiology (870) - Nuclear Medicine	2808 Old Post Road	Harrisburg	PA	Active
RRC390067-60	Child	RRC	PINNACLE HEALTH HOSPITALS	LAC - PHH - Nuclear Medicine (734) - Nuclear Medicine	1251 East Main Street	Annville	PA	Active
RRC390067-61	Child	RRC	PINNACLE HEALTH HOSPITALS	TCH - PHH - Nuclear Medicine (734) - Nuclear Medicine	240 Grandview Avenue	Camp Hill	PA	Active
RRC390067-62	Child	RRC	PINNACLE HEALTH HOSPITALS	TPY - PHH Cardiology (870) - Nuclear Medicine	2020 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-63	Child	RRC	PINNACLE HEALTH HOSPITALS	Hillman Cancer Center-Camphill (3004) - Hematology and Oncology	101 Erford Road	Camp Hill	PA	Terminated
RRC390067-64	Child	RRC	PINNACLE HEALTH HOSPITALS	GYN Oncology-York (39) - Gynecologic Oncology	1703 Innovation Drive	York	PA	Active
RRC390067-65	Child	RRC	PINNACLE HEALTH HOSPITALS	WS - Endoscopy - WS (3033) - Endoscopy	1995 Technology Parkway	Mechanicsburg	PA	Active
RRC390067-66	Child	RRC	PINNACLE HEALTH HOSPITALS	BLM - Heart Failure Center (221) - Heart Failure Clinic	4310 Londonderry Road	Harrisburg	PA	Active
RRC390067-67	Child	RRC	PINNACLE HEALTH HOSPITALS	FOC - Heart Failure Center (221) - Heart Failure Clinic	2005 Technology Parkway	Mechanicsburg	PA	Terminated
RRC390067-68	Child	RRC	PINNACLE HEALTH HOSPITALS	NOC - Heart Failure Center (221) - Heart Failure Clinic	300 Bretz Court	Newport	PA	Active
RRC390067-69	Child	RRC	PINNACLE HEALTH HOSPITALS	CRL - Heart Failure Center (221) - Heart Failure Clinic	360 Alexander Spring Road	Carlisle	PA	Active
RRC390067-70	Child	RRC	PINNACLE HEALTH HOSPITALS	LAC HCC Infusion (3096) - Outpatient Infusion/Injection Therapies	1251 East Main Street	Annville	PA	Active
RRC390067-71	Child	RRC	PINNACLE HEALTH HOSPITALS	UPMC Community Surgery Center (3070) - Surgery Center	815 Sir Thomas Court	Harrisburg	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Bedell, Stephen 340B Manager UPMC 7032325693	Camp, William Zacharie 340B Manager UPMC Presbyterian Shadyside 7406060376	10/15/2024 12:23 PM
Details	Last Recertification Date	Update	Recertification	8/16/2023 8:53:22 AM	9/6/2024 2:51:18 PM	9/6/2024 2:51 PM
Contacts	Primary Contact	Update	Group Change Request	Dudeck, Jennifer 340B Program Manager UPMC Central Pa. Region 7177823338	Bedell, Stephen 340B Manager UPMC 7032325693	10/24/2023 8:19 AM
Contacts	Authorizing Official	Update	Change Request	Baverso, Lou President, UPMC Central PA UPMC 7172303812	Mitstifer, Greg CFO UPMC Central PA 7172318245	8/31/2023 5:12 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2023 8:53 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000025630214	8/16/2023 8:53 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2023 8:53 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	8/16/2023 8:53 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1000025630215	8/16/2023 8:53 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	8/16/2023 8:53 AM
Details	Last Recertification Date	Update	Recertification	9/2/2022 12:17:33 PM	8/16/2023 8:53:22 AM	8/16/2023 8:53 AM
Contacts	Primary Contact	Update	Group Change Request	Dunsavage, Janice Director of Pharmacy UPMC Pinnacle 7177823338	Dudeck, Jennifer 340B Program Manager UPMC Central Pa. Region 7177823338	4/24/2023 7:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630043	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630057	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630059	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630102	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630105	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630166	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630167	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630168	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630169	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630170	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630171	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630186	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630187	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630188	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630189	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630190	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630192	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630195	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630196	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630202	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630203	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630204	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630207	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630208	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630211	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630212	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		1000025630213	3/14/2023 11:02 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1558731588	3/14/2023 11:02 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	3/14/2023 11:02 AM
Contacts	Authorizing Official	Update	Change Request	Bernhardt, Alison CFO UPMC Pinnacle 7172318245	Baverso, Lou President, UPMC Central PA UPMC 7172303812	12/30/2022 9:51 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 11:18:43 AM	9/2/2022 12:17:33 PM	9/2/2022 12:17 PM
Addresses	Billing Address	Update	Recertification	UPMC Pinnacle Harrisburg Attn: Pharmacy 111 South Front Street Harrisburg, PA 17101	UPMC Harrisburg Attn: Pharmacy 111 South Front Street Harrisburg, PA 17101	8/27/2021 11:18 AM
Details	Last Recertification Date	Update	Recertification		8/27/2021 11:18:43 AM	8/27/2021 11:18 AM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Bernhardt, Alison CFO UPMC Pinnacle 7172318245	5/6/2021 10:00 AM
Details	340B ID	Update	New Registration		RRC390067-31	5/6/2021 10:00 AM
Details	Entity Subname	Update	New Registration	CGOH - Echo-CGH (34)	CGOH - Echo-CGH (34) - Echo	5/6/2021 10:00 AM
Dates	Participating Approval Date	Update	New Registration		5/6/2021 10:00:45 AM	5/6/2021 10:00 AM
Details	State	Update	New Registration	Pending	Approved	5/6/2021 10:00 AM
Dates	Signed By Date	Update	New Registration		4/15/2021 8:48:10 AM	5/6/2021 10:00 AM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	5/6/2021 10:00 AM
Addresses	Main Address	Insert	New Registration		4300 Londonderry Road Harrisburg, PA 17109	4/9/2021 11:01 AM
Addresses	Billing Address	Insert	New Registration		UPMC Pinnacle Harrisburg Attn: Pharmacy 111 South Front Street Harrisburg, PA 17101	4/9/2021 11:01 AM
Addresses	Shipping Address	Insert	New Registration		UPMC Pinnacle Community Osteopathic 4300 Londonderry Road Harrisburg, PA 17109	4/9/2021 11:01 AM
Addresses	Shipping Address	Insert	New Registration		UPMC Pinnacle Harrisburg 111 South Front Street Harrisburg, PA 17101	4/9/2021 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1164526588	4/9/2021 11:01 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/9/2021 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1265537674	4/9/2021 11:01 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/9/2021 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1346344769	4/9/2021 11:01 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/9/2021 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1407813603	4/9/2021 11:01 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/9/2021 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1922425651	4/9/2021 11:01 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/9/2021 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1972613305	4/9/2021 11:01 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/9/2021 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1255437638	4/9/2021 11:01 AM
Medicaid Billing	NPI: State	Insert	New Registration		PA	4/9/2021 11:01 AM
Contacts	Primary Contact	Insert	New Registration		Dunsavage, Janice Director of Pharmacy UPMC Pinnacle 7177823338	4/9/2021 11:01 AM
Contacts	Authorizing Official	Insert	New Registration		Bernhardt, Alison CFO UPMC Pinnacle 7172318245	4/9/2021 11:01 AM
Details	Assistance Received From Date	Insert	New Registration			4/9/2021 11:01 AM
Details	Assistance Received To Date	Insert	New Registration			4/9/2021 11:01 AM
Details	Last Recertification Date	Insert	New Registration			4/9/2021 11:01 AM
Details	Grant Number	Insert	New Registration			4/9/2021 11:01 AM
Details	340B ID	Insert	New Registration			4/9/2021 11:01 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/9/2021 11:01 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/9/2021 11:01 AM
Details	Medicare Provider Number	Insert	New Registration		390067	4/9/2021 11:01 AM
Details	Entity Name	Insert	New Registration		PINNACLE HEALTH HOSPITALS	4/9/2021 11:01 AM
Details	NOFO Number	Insert	New Registration			4/9/2021 11:01 AM
Details	Program Code	Insert	New Registration		RRC	4/9/2021 11:01 AM
Details	Entity Subname	Insert	New Registration		CGOH - Echo-CGH (34)	4/9/2021 11:01 AM
Dates	Participating Approval Date	Insert	New Registration			4/9/2021 11:01 AM
Details	State	Insert	New Registration		Pending	4/9/2021 11:01 AM
Dates	Registration Date	Insert	New Registration		4/9/2021 11:01:21 AM	4/9/2021 11:01 AM
Dates	Signed By Date	Insert	New Registration			4/9/2021 11:01 AM
Dates	Start Date	Insert	New Registration			4/9/2021 11:01 AM
Terminations	Termination Comments	Insert	New Registration			4/9/2021 11:01 AM
Terminations	Termination Date	Insert	New Registration			4/9/2021 11:01 AM
Terminations	Termination Effective Date	Insert	New Registration			4/9/2021 11:01 AM
Terminations	Termination Reason	Insert	New Registration			4/9/2021 11:01 AM