Covered Entity Details

DSH070007AF LAWRENCE & MEMORIAL HOSPITAL (Active) - information as of 5/27/2025 11:38:01 PM

Main Details

Name

LAWRENCE & MEMORIAL HOSPITAL

Subdivision Name

LMH MED ONC URO MDC WATERFORD - Oncology and Urology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH070007AF

Medicare Provider Number

070007

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2021

Participating Start Date

7/1/2021

Participating Approval Date

4/13/2021

Last Recertification Date

9/3/2024

Contacts

Authorizing Official

Yale New Haven Health Services
Leeann Miller, Chief Pharmacy Officer
(203) 479-3000

Primary Contact

Yale New Haven Health System
Maria Da Silva, Senior Reimbursement Analyst
(203) 688-9332

Addresses

Street Address

230 Waterford Parkway South
Waterford, CT 06385

Billing Address

Lawrence and Memorial Hospital
365 Montauk Ave
New London, CT 06320

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
CT	004041679,004024972	1073530879,1700092459
MA	110066612A,110066612B	1073530879,1700092459
RI	1073530879	1073530879,1700092459
NY	00410811	1073530879,1700092459

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
DSH070007A	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M PEQUOT CT SCAN	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007AA	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH CARDIOLOGY LIMB WATERFORD - Cardiovascular Disease	40 Boston Post Road	WATERFORD	CT	Active
DSH070007AB	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PEQUOT REHAB SERVICES - Rehabilitation	52 Hazelnut Hill Road	Groton	CT	Active
DSH070007AC	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH FAIRE HARBOUR REHAB SERVICES - Rehabilitation	59 Faire Harbour	NEW LONDON	CT	Active
DSH070007AD	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH CANCER CENTER GYN ONC - GYN ONC Clinic	230 Waterford Parkway South	Waterford	CT	Active
DSH070007AE	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PODIATRY LIMB WATERFORD - Podiatry	40 Boston Post Road	Waterford	CT	Active
DSH070007AF	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH MED ONC URO MDC WATERFORD - Oncology and Urology	230 Waterford Parkway South	Waterford	CT	Active
DSH070007AG	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH VASCULAR SURG LIMB WATERFORD - Vascular Surgery	40 Boston Post Road	Waterford	CT	Active
DSH070007AH	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH Smilow Liver Clinic Waterford - Cancer	230 Waterford Pkwy S	Waterford	CT	Active
DSH070007AJ	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH SMILOW HEAD & NECK WATERFORD - Cancer Center	230 Waterford Pkwy S	Waterford	CT	ToBeTerminated
DSH070007AK	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PEQUOT PRE/POST - PRE and POST	52 Hazelnut Hill Road	Groton	CT	ToBeTerminated
DSH070007AL	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH CANCER CENTER ANTI COAG CLINIC - Clinic	230 Waterford Parkway South	WATERFORD	CT	Approved
DSH070007AM	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PODIATRY LIMB PRESERVATION - Wound Care clinic	52 Hazelnut Hill road	GROTON	CT	Approved
DSH070007B	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M CROSSROADS CT SCAN	196 Parkway South, Suite 102	Waterford	CT	Terminated
DSH070007C	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M CROSSROADS NUCLEAR MEDICINE	196 Parkway South Suite 102	Waterford	CT	Terminated
DSH070007D	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH EMERGENCY PEQUOT	52 Hazelnut Hill Road	Groton	CT	Active
DSH070007E	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Crossroads Mamo-Breast Imaging	196 Parkway South	Waterford	CT	Terminated
DSH070007F	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Pequot Mamo-Breast Imaging	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007G	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Crossroads MRI Services	196 Parkway South	Waterford	CT	Terminated
DSH070007H	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Pequot MRI Services	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007J	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH SLEEP LAB	224 Gold Star Highway	Groton	CT	Active
DSH070007K	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH WOUND CARE CENTER	40 Boston Post Road	Waterford	CT	Active
DSH070007L	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Waterfall Therapy Services	40 Boston Post Road	Waterford	CT	Terminated
DSH070007M	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Crossroads Radiology Services	196 Pakway South	Waterford	CT	Terminated
DSH070007N	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Flanders Therapy Services	339 Flanders Road	East Lyme	CT	Terminated
DSH070007P	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Pequot Therapy Services	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007Q	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M Pequot Radiology Services	52 Hazelnut Hill Road	Groton	CT	Terminated
DSH070007R	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PEQUOT OR	52 Hazelnut Hill Road	Groton	CT	ToBeTerminated
DSH070007S	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH CANCER CENTER MED ONC	230 Waterford Parkway South	Waterford	CT	Active
DSH070007T	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M CANCER CENTER - LMH CANCER CENTER RADIATION ONCOLOGY	230 WATERFORD PKWY South	WATERFORD	CT	Active
DSH070007U	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	L+M PEQUOT HEALTH CENTER - LMH PEQUOT PERIOP SERVICES	52 HAZELNUT HILL RD	GROTON	CT	Active
DSH070007V	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH PFT - PULMONARY FUNCTION TESTING SERVICES	365 MONTAUK AVENUE	NEW LONDON	CT	Terminated
DSH070007W	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH VASCULAR SURGERY LIMB PRESERVATION - VASCULAR LIMB SERVICE	52 HAZELNUT HILL ROAD	GROTON	CT	Terminated
DSH070007X	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH SURGERY BREAST WATERFORD - BREAST SURGERY	230 WATERFORD PARKWAY SOUTH	WATERFORD	CT	Approved
DSH070007Y	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH FLANDERS REHAB SERVICES - Rehabilitation	339 Flanders Road	East Lyme	CT	Active
DSH070007Z	Child	DSH	LAWRENCE & MEMORIAL HOSPITAL	LMH WATERFALL REHABILITATION - Rehabilitation	40 Boston Post Road	Waterford	CT	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/26/2023 4:37:31 PM	9/3/2024 10:57:52 PM	9/3/2024 10:57 PM
Details	Last Recertification Date	Update	Recertification	9/14/2022 2:18:08 PM	8/26/2023 4:37:31 PM	8/26/2023 4:37 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	51106144 (AK)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	004167 (AZ)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	9000161963 (CO)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	003194255A (GA)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1761826 (LA)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1073530879 (ME)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1073530879 (NC)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10026753600 (NE)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	4079302 (NJ)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	85286737 (NM)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10410B (SC)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	10463A (SC)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1073530879 (CA)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	011409703 (MO)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	0038944 (OH)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	01260157 (KY)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	023456500 (FL)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	060646704002 (IL)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	81130700 (WI)		6/5/2023 9:49 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	300041719 (IN)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (AK)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (AK)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (AZ)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (AZ)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (CO)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (CO)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (FL)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (FL)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (GA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (GA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (IL)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (IL)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (KY)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (KY)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (LA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (LA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (ME)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (ME)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (MO)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (MO)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (NC)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (NC)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (NE)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (NE)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (NJ)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (NJ)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (NM)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (NM)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (OH)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (OH)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (SC)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (SC)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (WI)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (WI)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (CA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (CA)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1073530879 (IN)		6/5/2023 9:49 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1700092459 (IN)		6/5/2023 9:49 AM
Contacts	Authorizing Official	Update	Change Request	Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	Miller, Leeann Chief Pharmacy Officer Yale New Haven Health Services 2034793000	10/17/2022 8:21 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1073530879 (WI)		9/14/2022 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2022 2:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		81130700	9/14/2022 2:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/14/2022 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2022 2:18 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300041719	9/14/2022 2:18 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/14/2022 2:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1073530879	9/14/2022 2:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/14/2022 2:18 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1700092459	9/14/2022 2:18 PM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/14/2022 2:18 PM
Details	Last Recertification Date	Update	Recertification	9/10/2021 5:26:13 PM	9/14/2022 2:18:08 PM	9/14/2022 2:18 PM
Addresses	Billing Address	Update	Recertification	Lawrence and Memorial Hospital 365 Montauk Ave Ne London, CT 06320	Lawrence and Memorial Hospital 365 Montauk Ave New London, CT 06320	9/10/2021 5:26 PM
Details	Last Recertification Date	Update	Recertification		9/10/2021 5:26:13 PM	9/10/2021 5:26 PM
Medicaid Billing	Medicaid: State	Update	Change Request	AR	AK	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	23456500 (FL)		8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	60646704002 (IL)		8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1260157 (KY)		8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11409703 (MO)		8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	410811 (NY)		8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	38944 (OH)		8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		011409703	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0038944	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		01260157	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		00410811	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		023456500	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		060646704002	8/9/2021 1:45 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	8/9/2021 1:45 PM
Medicaid Billing	NPI: State	Update	Change Request	AR	AK	8/9/2021 1:45 PM
Medicaid Billing	NPI: State	Update	Change Request	AR	AK	8/9/2021 1:45 PM
Details	State	Update		Approved	Active	7/1/2021 12:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		51106144	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AR	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		004167	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		AZ	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		9000161963	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		23456500	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		003194255A	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		60646704002	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1260157	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		KY	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1761826	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110066612A	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		110066612B	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MA	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		ME	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		11409703	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MO	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10026753600	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NE	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4079302	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		85286737	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NM	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		410811	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NY	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		38944	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		OH	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		RI	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10410B	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10463A	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CA	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		AR	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		AR	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		AZ	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		GA	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		GA	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		IL	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		KY	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		MA	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		MA	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		ME	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		ME	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		MO	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NE	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NE	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NJ	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NM	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NM	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		NY	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		OH	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		RI	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		RI	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		WI	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1073530879	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/20/2021 11:47 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1700092459	4/20/2021 11:47 AM
Medicaid Billing	NPI: State	Insert	Change Request		CA	4/20/2021 11:47 AM
Addresses	Shipping Address	Delete	Change Request	Lawerence and Memorial Hospital 365 Montauk Avenue New London, CT 06320		4/20/2021 9:38 AM
Addresses	Billing Address	Insert	Change Request		Lawrence and Memorial Hospital 365 Montauk Ave Ne London, CT 06320	4/20/2021 9:38 AM
Contacts	Signed By	Insert	New Registration		Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	4/13/2021 10:04 AM
Details	340B ID	Update	New Registration		DSH070007AF	4/13/2021 10:04 AM
Details	Entity Subname	Update	New Registration	LMH MED ONC URO MDC WATERFORD	LMH MED ONC URO MDC WATERFORD - Oncology and Urology	4/13/2021 10:04 AM
Dates	Participating Approval Date	Update	New Registration		4/13/2021 10:04:40 AM	4/13/2021 10:04 AM
Details	State	Update	New Registration	Pending	Approved	4/13/2021 10:04 AM
Dates	Signed By Date	Update	New Registration		4/13/2021 9:30:46 AM	4/13/2021 10:04 AM
Dates	Start Date	Update	New Registration		7/1/2021 12:00:00 AM	4/13/2021 10:04 AM
Addresses	Main Address	Insert	New Registration		230 Waterford Parkway South Waterford, CT 06385	4/12/2021 1:36 PM
Addresses	Shipping Address	Insert	New Registration		Lawerence and Memorial Hospital 365 Montauk Avenue New London, CT 06320	4/12/2021 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2021 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004041679	4/12/2021 1:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/12/2021 1:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2021 1:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		004024972	4/12/2021 1:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CT	4/12/2021 1:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1073530879	4/12/2021 1:36 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/12/2021 1:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1700092459	4/12/2021 1:36 PM
Medicaid Billing	NPI: State	Insert	New Registration		CT	4/12/2021 1:36 PM
Contacts	Authorizing Official	Insert	New Registration		Messina, Mary G Director, Regulatory Reimbursement YNHHS Yale New Haven Health System 2036888543	4/12/2021 1:36 PM
Contacts	Primary Contact	Insert	New Registration		Da Silva, Maria Senior Reimbursement Analyst Yale New Haven Health System 2036889332	4/12/2021 1:36 PM
Details	Assistance Received From Date	Insert	New Registration			4/12/2021 1:36 PM
Details	Assistance Received To Date	Insert	New Registration			4/12/2021 1:36 PM
Details	Last Recertification Date	Insert	New Registration			4/12/2021 1:36 PM
Details	Grant Number	Insert	New Registration			4/12/2021 1:36 PM
Details	340B ID	Insert	New Registration			4/12/2021 1:36 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/12/2021 1:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/12/2021 1:36 PM
Details	Medicare Provider Number	Insert	New Registration		070007	4/12/2021 1:36 PM
Details	Entity Name	Insert	New Registration		LAWRENCE & MEMORIAL HOSPITAL	4/12/2021 1:36 PM
Details	NOFO Number	Insert	New Registration			4/12/2021 1:36 PM
Details	Program Code	Insert	New Registration		DSH	4/12/2021 1:36 PM
Details	Entity Subname	Insert	New Registration		LMH MED ONC URO MDC WATERFORD	4/12/2021 1:36 PM
Dates	Participating Approval Date	Insert	New Registration			4/12/2021 1:36 PM
Details	State	Insert	New Registration		Pending	4/12/2021 1:36 PM
Dates	Registration Date	Insert	New Registration		4/12/2021 1:36:30 PM	4/12/2021 1:36 PM
Dates	Signed By Date	Insert	New Registration			4/12/2021 1:36 PM
Dates	Start Date	Insert	New Registration			4/12/2021 1:36 PM
Terminations	Termination Comments	Insert	New Registration			4/12/2021 1:36 PM
Terminations	Termination Date	Insert	New Registration			4/12/2021 1:36 PM
Terminations	Termination Effective Date	Insert	New Registration			4/12/2021 1:36 PM
Terminations	Termination Reason	Insert	New Registration			4/12/2021 1:36 PM