Covered Entity Details

CH01064K Northern Counties Health Care, Inc (Active) - information as of 6/23/2025 11:58:30 PM

Main Details

Name

Northern Counties Health Care, Inc

Subdivision Name

Northern Express Care St. Johnsbury

Type

HRSA-Funded Health Center

Site ID

BPS-H80-036971

340B ID

CH01064K

Grant Number

H80CS00632

Additional Details

Current Program Status

Active

Registration Date

1/3/2022

Participating Start Date

4/1/2022

Participating Approval Date

1/6/2022

Last Recertification Date

2/13/2025

Contacts

Authorizing Official

Northern Counties Health Care
Angela Neil, CFO
(802) 748-9405 Ext: 1599

Primary Contact

Northern Counties Health Care Inc
Michelle Farmer, Accounting Manager
(802) 748-9405

Addresses

Street Address

457 Railroad Street STE 2
St Johnsbury, VT 05819

Billing Address

Northern Counties Health Care
165 Sherman Dr
St Johnsbury, VT 05819

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?
No

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.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH010640	Active	BPS-H80-005349	NORTHERN COUNTIES HEALTH CARE, INC	NORTHERN COUNTIES HEALTH CARE, INC.	165 Sherman Dr	Saint Johnsbury	VT
CH01064A	Active	BPS-H80-003808	NORTHERN COUNTIES HEALTH CARE, INC	ISLAND POND HEALTH CENTER	82 MAPLE STREET	ISLAND POND	VT
CH01064D	Active	BPS-H80-001814	NORTHERN COUNTIES HEALTH CARE, INC	DANVILLE HEALTH CENTER	26 Cedar Ln	Danville	VT
CH01064F	Active	BPS-H80-008756	NORTHERN COUNTIES HEALTH CARE, INC	Hardwick Area Health Center	4 Slapp HI	Hardwick	VT
CH01064G	Active	BPS-H80-003571	NORTHERN COUNTIES HEALTH CARE, INC	CONCORD HEALTH CENTER	201 EAST MAIN STREET	CONCORD	VT
CH01064I	Active	BPS-H80-001222	NORTHERN COUNTIES HEALTH CARE, INC	ST. JOHNSBURY COMMUNITY HEALTH CENTER	185 Sherman Dr	Saint Johnsbury	VT
CH01064K	Active	BPS-H80-036971	Northern Counties Health Care, Inc	Northern Express Care St. Johnsbury	457 Railroad Street STE 2	St Johnsbury	VT
CH01064L	Active	BPS-H80-018115	NORTHERN COUNTIES HEALTH CARE INC	Orleans Dental Center	11 Union St	Orleans	VT
CH01064M	Active	BPS-H80-000671	NORTHERN COUNTIES HEALTH CARE INC	NORTHERN COUNTIES DENTAL CENTER	151 NORTH MAIN STREET	HARDWICK	VT
CH01064N	Active	BPS-H80-004761	NORTHERN COUNTIES HEALTH CARE INC	Island Pond Dental Center	82 Maple St	Island Pond	VT
CH01064P	Active	BPS-H80-034432	NORTHERN COUNTIES HEALTH CARE INC	Northern Express Care Newport	137 Main St STE 102	Newport	VT

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH01064G	COMMUNITY HEALTH PHARMACY	158 BRENTWOOD DR STE 6		COLCHESTER	VT	05446-7994	11/01/2008
CH01064A	COMMUNITY HEALTH PHARMACY	158 BRENTWOOD DR STE 6		COLCHESTER	VT	05446-7994	11/01/2008
CH01064F	COMMUNITY HEALTH PHARMACY	158 BRENTWOOD DR STE 6		COLCHESTER	VT	05446-7994	11/01/2008
CH01064D	COMMUNITY HEALTH PHARMACY	158 BRENTWOOD DR STE 6		COLCHESTER	VT	05446-7994	11/01/2008
CH01064I	COMMUNITY HEALTH PHARMACY	158 BRENTWOOD DR STE 6		COLCHESTER	VT	05446-7994	11/01/2008
CH010640	COMMUNITY HEALTH PHARMACY	158 BRENTWOOD DR STE 6		COLCHESTER	VT	05446-7994	11/01/2008
CH01064P	COMMUNITY HEALTH PHARMACY	158 BRENTWOOD DR STE 6		COLCHESTER	VT	05446-7994	07/01/2023
CH01064G	GAUTHIER'S PHARMACY	415 RAILROAD STREET		ST. JOHNSBURY	VT	05819	07/05/2012	03/14/2019
CH01064A	GAUTHIER'S PHARMACY	415 RAILROAD STREET		ST. JOHNSBURY	VT	05819	07/05/2012	03/14/2019
CH01064F	GAUTHIER'S PHARMACY	415 RAILROAD STREET		ST. JOHNSBURY	VT	05819	07/05/2012	03/14/2019
CH01064D	GAUTHIER'S PHARMACY	415 RAILROAD STREET		ST. JOHNSBURY	VT	05819	07/05/2012	03/14/2019
CH01064I	GAUTHIER'S PHARMACY	415 RAILROAD STREET		ST. JOHNSBURY	VT	05819	07/05/2012	03/14/2019
CH010640	GAUTHIER'S PHARMACY	415 RAILROAD STREET		ST. JOHNSBURY	VT	05819	07/05/2012	03/14/2019
CH01064G	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #93	957 MEMORIAL DRIVE	SAINT JOHNSBURY	VT	05819	07/06/2012
CH01064G	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #94	407 BROAD STREET	LYNDONVILLE	VT	05851	07/06/2012
CH01064G	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #58	55 SHATTUCK HILL ROAD	NEWPORT	VT	05855	07/11/2012
CH01064G	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #23	97 MORRISVILLE PLAZA PO BOX 979	MORRISVILLE	VT	05661	07/11/2012
CH01064A	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #58	55 SHATTUCK HILL ROAD	NEWPORT	VT	05855	07/06/2012
CH01064A	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #93	957 MEMORIAL DRIVE	SAINT JOHNSBURY	VT	05819	07/06/2012
CH01064A	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #94	407 BROAD STREET	LYNDONVILLE	VT	05851	07/06/2012
CH01064A	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #23	97 MORRISVILLE PLAZA PO BOX 979	MORRISVILLE	VT	05661	07/11/2012
CH01064F	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #58	55 SHATTUCK HILL ROAD	NEWPORT	VT	05855	07/06/2012
CH01064F	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #23	97 MORRISVILLE PLAZA PO BOX 979	MORRISVILLE	VT	05661	07/06/2012
CH01064F	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #93	957 MEMORIAL DRIVE	SAINT JOHNSBURY	VT	05819	07/06/2012
CH01064F	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #94	407 BROAD STREET	LYNDONVILLE	VT	05851	07/06/2012
CH01064D	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #23	97 MORRISVILLE PLAZA PO BOX 979	MORRISVILLE	VT	05661	07/06/2012
CH01064D	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #93	957 MEMORIAL DRIVE	SAINT JOHNSBURY	VT	05819	07/06/2012
CH01064D	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #94	407 BROAD STREET	LYNDONVILLE	VT	05851	07/06/2012
CH01064D	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #58	55 SHATTUCK HILL ROAD	NEWPORT	VT	05855	07/11/2012
CH01064I	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #93	957 MEMORIAL DRIVE	SAINT JOHNSBURY	VT	05819	07/06/2012
CH01064I	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #94	407 BROAD STREET	LYNDONVILLE	VT	05851	07/06/2012
CH01064I	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #58	55 SHATTUCK HILL ROAD	NEWPORT	VT	05855	07/11/2012
CH01064I	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #23	97 MORRISVILLE PLAZA PO BOX 979	MORRISVILLE	VT	05661	07/11/2012
CH010640	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #23	97 MORRISVILLE PLAZA PO BOX 979	MORRISVILLE	VT	05661	07/30/2012
CH010640	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #58	55 SHATTUCK HILL ROAD	NEWPORT	VT	05855	07/30/2012
CH010640	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #93	957 MEMORIAL DRIVE	SAINT JOHNSBURY	VT	05819	07/30/2012
CH010640	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #94	407 BROAD STREET	LYNDONVILLE	VT	05851	07/30/2012
CH010640	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #120	12 RAILROAD ST	ISLAND POND	VT	05846-9716	01/01/2015	12/31/2016
CH01064P	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #58	55 SHATTUCK HILL ROAD	NEWPORT	VT	05855	07/01/2023
CH01064P	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #93	957 MEMORIAL DRIVE	SAINT JOHNSBURY	VT	05819	07/01/2023
CH01064P	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #94	407 BROAD STREET	LYNDONVILLE	VT	05851	07/01/2023
CH01064P	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #23	97 MORRISVILLE PLAZA PO BOX 979	MORRISVILLE	VT	05661	07/01/2023
CH010640	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #106	471 EAST MAIN STREET SUITE 2	GOUVERNEUR	NY	13642	10/01/2024	01/06/2025
CH01064A	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #106	471 EAST MAIN STREET SUITE 2	GOUVERNEUR	NY	13642	10/01/2024	01/06/2025
CH01064D	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #106	471 EAST MAIN STREET SUITE 2	GOUVERNEUR	NY	13642	10/01/2024	01/06/2025
CH01064F	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #106	471 EAST MAIN STREET SUITE 2	GOUVERNEUR	NY	13642	10/01/2024	01/06/2025
CH01064G	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #106	471 EAST MAIN STREET SUITE 2	GOUVERNEUR	NY	13642	10/01/2024	01/06/2025
CH01064I	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #106	471 EAST MAIN STREET SUITE 2	GOUVERNEUR	NY	13642	10/01/2024	01/06/2025
CH01064L	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #106	471 EAST MAIN STREET SUITE 2	GOUVERNEUR	NY	13642	10/01/2024
CH01064P	KPH HEALTHCARE SERVICES, INC.	KINNEY DRUGS #106	471 EAST MAIN STREET SUITE 2	GOUVERNEUR	NY	13642	10/01/2024	01/06/2025
CH010640	KPH HEALTHCARE SERVICES, INC.	DBA: KINNEY DRUGS CF	471 E MAIN ST UNIT 5	GOUVERNEUR	NY	13642	01/06/2025
CH01064A	KPH HEALTHCARE SERVICES, INC.	DBA: KINNEY DRUGS CF	471 E MAIN ST UNIT 5	GOUVERNEUR	NY	13642	01/06/2025
CH01064D	KPH HEALTHCARE SERVICES, INC.	DBA: KINNEY DRUGS CF	471 E MAIN ST UNIT 5	GOUVERNEUR	NY	13642	01/06/2025
CH01064F	KPH HEALTHCARE SERVICES, INC.	DBA: KINNEY DRUGS CF	471 E MAIN ST UNIT 5	GOUVERNEUR	NY	13642	01/06/2025
CH01064G	KPH HEALTHCARE SERVICES, INC.	DBA: KINNEY DRUGS CF	471 E MAIN ST UNIT 5	GOUVERNEUR	NY	13642	01/06/2025
CH01064I	KPH HEALTHCARE SERVICES, INC.	DBA: KINNEY DRUGS CF	471 E MAIN ST UNIT 5	GOUVERNEUR	NY	13642	01/06/2025
CH01064P	KPH HEALTHCARE SERVICES, INC.	DBA: KINNEY DRUGS CF	471 E MAIN ST UNIT 5	GOUVERNEUR	NY	13642	01/06/2025
CH01064G	MAXI GREEN, INC.	RITE AID #10335	502 RAILROAD STREET	ST. JOHNSBURY	VT	05819	09/12/2012	01/31/2018
CH01064G	MAXI GREEN, INC.	RITE AID #10337	412 BROAD STREET	LYNDONVILLE	VT	05851	09/12/2012	01/31/2018
CH01064G	MAXI GREEN, INC.	RITE AID #10336	82 ROUTE 15 WEST	HARDWICK	VT	05843	09/12/2012	01/31/2018
CH01064G	MAXI GREEN, INC.	RITE AID #10330	48 CONGRESS STREET PO BOX 731	MORRISVILLE	VT	05661	09/12/2012	01/31/2018
CH01064A	MAXI GREEN, INC.	RITE AID #10335	502 RAILROAD STREET	ST. JOHNSBURY	VT	05819	09/12/2012	01/31/2018
CH01064A	MAXI GREEN, INC.	RITE AID #10337	412 BROAD STREET	LYNDONVILLE	VT	05851	09/12/2012	01/31/2018
CH01064A	MAXI GREEN, INC.	RITE AID #10336	82 ROUTE 15 WEST	HARDWICK	VT	05843	09/12/2012	01/31/2018
CH01064A	MAXI GREEN, INC.	RITE AID #10330	48 CONGRESS STREET PO BOX 731	MORRISVILLE	VT	05661	09/12/2012	01/31/2018
CH01064F	MAXI GREEN, INC.	RITE AID #10335	502 RAILROAD STREET	ST. JOHNSBURY	VT	05819	09/12/2012	01/31/2018
CH01064F	MAXI GREEN, INC.	RITE AID #10337	412 BROAD STREET	LYNDONVILLE	VT	05851	09/12/2012	01/31/2018
CH01064F	MAXI GREEN, INC.	RITE AID #10336	82 ROUTE 15 WEST	HARDWICK	VT	05843	09/12/2012	01/31/2018
CH01064F	MAXI GREEN, INC.	RITE AID #10330	48 CONGRESS STREET PO BOX 731	MORRISVILLE	VT	05661	09/12/2012	01/31/2018
CH01064D	MAXI GREEN, INC.	RITE AID #10335	502 RAILROAD STREET	ST. JOHNSBURY	VT	05819	09/12/2012	01/31/2018
CH01064D	MAXI GREEN, INC.	RITE AID #10337	412 BROAD STREET	LYNDONVILLE	VT	05851	09/12/2012	01/31/2018
CH01064D	MAXI GREEN, INC.	RITE AID #10336	82 ROUTE 15 WEST	HARDWICK	VT	05843	09/12/2012	01/31/2018
CH01064D	MAXI GREEN, INC.	RITE AID #10330	48 CONGRESS STREET PO BOX 731	MORRISVILLE	VT	05661	09/12/2012	01/31/2018
CH01064I	MAXI GREEN, INC.	RITE AID #10335	502 RAILROAD STREET	ST. JOHNSBURY	VT	05819	09/12/2012	01/31/2018
CH01064I	MAXI GREEN, INC.	RITE AID #10337	412 BROAD STREET	LYNDONVILLE	VT	05851	09/12/2012	01/31/2018
CH01064I	MAXI GREEN, INC.	RITE AID #10336	82 ROUTE 15 WEST	HARDWICK	VT	05843	09/12/2012	01/31/2018
CH01064I	MAXI GREEN, INC.	RITE AID #10330	48 CONGRESS STREET PO BOX 731	MORRISVILLE	VT	05661	09/12/2012	01/31/2018
CH010640	MAXI GREEN, INC.	RITE AID #10335	502 RAILROAD STREET	ST. JOHNSBURY	VT	05819	09/12/2012	01/31/2018
CH010640	MAXI GREEN, INC.	RITE AID #10337	412 BROAD STREET	LYNDONVILLE	VT	05851	09/12/2012	01/31/2018
CH010640	MAXI GREEN, INC.	RITE AID #10336	82 ROUTE 15 WEST	HARDWICK	VT	05843	09/12/2012	01/31/2018
CH010640	MAXI GREEN, INC.	RITE AID #10330	48 CONGRESS STREET PO BOX 731	MORRISVILLE	VT	05661	09/12/2012	01/31/2018
CH01064G	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4182	136 MEADOW STREET	LITTLETON	NH	03561	09/12/2012	01/31/2018
CH01064A	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4182	136 MEADOW STREET	LITTLETON	NH	03561	09/12/2012	01/31/2018
CH01064F	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4182	136 MEADOW STREET	LITTLETON	NH	03561	09/12/2012	01/31/2018
CH01064D	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4182	136 MEADOW STREET	LITTLETON	NH	03561	09/12/2012	01/31/2018
CH01064I	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4182	136 MEADOW STREET	LITTLETON	NH	03561	09/12/2012	01/31/2018
CH010640	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4182	136 MEADOW STREET	LITTLETON	NH	03561	09/12/2012	01/31/2018
CH010640	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4127	177 MAIN STREET	LANCASTER	NH	03584	04/01/2019	01/14/2019
CH010640	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2017
CH01064P	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/01/2023
CH010640	WAL-MART PHARMACY 10-2681	615 MEADOW STREET		LITTLETON	NH	03561	04/01/2014
CH01064P	WAL-MART PHARMACY 10-2681	615 MEADOW STREET		LITTLETON	NH	03561	07/01/2023
CH010640	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2017
CH010640	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 10410	274 DELLS ROAD	LITTLETON	NH	03561	04/01/2018
CH010640	WALGREEN EASTERN CO., INC.	WALGREENS #17625	412 BROAD ST	LYNDONVILLE	VT	05851	02/08/2018
CH010640	WALGREEN EASTERN CO., INC.	WALGREENS #17185	82 VT ROUTE 15 W	HARDWICK	VT	05843	02/08/2018
CH010640	WALGREEN EASTERN CO., INC.	WALGREENS #18977	48 CONGRESS ST	MORRISVILLE	VT	05661	02/08/2018	03/21/2023
CH010640	WALGREEN EASTERN CO., INC.	WALGREENS #18090	502 RAILROAD ST.	SAINT JOHNSBURY	VT	05819	02/08/2018	02/22/2023
CH010640	WALGREEN EASTERN CO., INC.	WALGREENS #17167	177 MAIN ST.	LANCASTER	NH	03584	07/01/2019
CH010640	WALGREEN EASTERN CO., INC.	RITE AID #04159	4408 U S ROUTE 5	NEWPORT	VT	05855	07/01/2019	02/17/2020
CH01064P	WALGREEN EASTERN CO., INC.	WALGREENS #18977	48 CONGRESS ST	MORRISVILLE	VT	05661	07/01/2023
CH01064P	WALGREEN EASTERN CO., INC.	RITE AID #04159	4408 U S ROUTE 5	NEWPORT	VT	05855	07/01/2023
CH01064P	WALGREEN EASTERN CO., INC.	WALGREENS #17185	82 VT ROUTE 15 W	HARDWICK	VT	05843	07/01/2023
CH01064A	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/01/2023
CH010640	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/01/2023
CH01064D	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/01/2023
CH01064F	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/01/2023
CH01064G	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/01/2023
CH01064I	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/01/2023
CH01064P	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/01/2023
CH010640	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	04/01/2018
CH010640	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	04/01/2018
CH010640	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/1/2024 10:39:06 PM	2/13/2025 9:46:58 AM	2/13/2025 9:46 AM
Contacts	Authorizing Official	Update	AO Change Request	Costa, Michael CEO Northern Counties Health Care 8027489405-1513	Neil, Angela CFO Northern Counties Health Care 8027489405-1599	2/13/2025 8:31 AM
Contacts	Primary Contact	Update	AO Change Request	Neil, Angela CFO Northern Counties Health Care 8027489405-1599	Farmer, Michelle Accounting Manager Northern Counties Health Care Inc 8027489405	2/13/2025 8:31 AM
Details	Last Recertification Date	Update	Recertification	2/14/2023 6:59:20 AM	2/1/2024 10:39:06 PM	2/1/2024 10:39 PM
Addresses	Main Address	Update	Change Request	1 Eastern Ave Saint Johnsbury, VT 05819-2661	457 Railroad Street STE 2 St Johnsbury, VT 05819	9/14/2023 10:01 AM
Details	Last Recertification Date	Update	Recertification		2/14/2023 6:59:20 AM	2/14/2023 6:59 AM
Details	State	Update		Approved	Active	4/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Costa, Michael CEO Northern Counties Health Care 8027489405-1513	1/6/2022 12:34 PM
Details	340B ID	Update	New Registration		CH01064K	1/6/2022 12:34 PM
Dates	Participating Approval Date	Update	New Registration		1/6/2022 12:34:25 PM	1/6/2022 12:34 PM
Details	State	Update	New Registration	Pending	Approved	1/6/2022 12:34 PM
Dates	Signed By Date	Update	New Registration		1/6/2022 10:42:30 AM	1/6/2022 12:34 PM
Dates	Start Date	Update	New Registration		4/1/2022 12:00:00 AM	1/6/2022 12:34 PM
Addresses	Main Address	Insert	New Registration		1 Eastern Ave Saint Johnsbury, VT 05819-2661	1/3/2022 2:03 PM
Addresses	Billing Address	Insert	New Registration		Northern Counties Health Care 165 Sherman Dr St Johnsbury, VT 05819	1/3/2022 2:03 PM
Contacts	Primary Contact	Insert	New Registration		Neil, Angela CFO Northern Counties Health Care 8027489405-1599	1/3/2022 2:03 PM
Contacts	Authorizing Official	Insert	New Registration		Costa, Michael CEO Northern Counties Health Care 8027489405-1513	1/3/2022 2:03 PM
Details	Assistance Received From Date	Insert	New Registration			1/3/2022 2:03 PM
Details	Assistance Received To Date	Insert	New Registration			1/3/2022 2:03 PM
Details	Last Recertification Date	Insert	New Registration			1/3/2022 2:03 PM
Details	Grant Number	Insert	New Registration		H80CS00632	1/3/2022 2:03 PM
Details	340B ID	Insert	New Registration			1/3/2022 2:03 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/3/2022 2:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/3/2022 2:03 PM
Details	Medicare Provider Number	Insert	New Registration			1/3/2022 2:03 PM
Details	Entity Name	Insert	New Registration		Northern Counties Health Care, Inc	1/3/2022 2:03 PM
Details	NOFO Number	Insert	New Registration			1/3/2022 2:03 PM
Details	Program Code	Insert	New Registration		CH	1/3/2022 2:03 PM
Details	Entity Subname	Insert	New Registration		Northern Express Care St. Johnsbury	1/3/2022 2:03 PM
Dates	Participating Approval Date	Insert	New Registration			1/3/2022 2:03 PM
Details	State	Insert	New Registration		Pending	1/3/2022 2:03 PM
Dates	Registration Date	Insert	New Registration		1/3/2022 2:03:29 PM	1/3/2022 2:03 PM
Dates	Signed By Date	Insert	New Registration			1/3/2022 2:03 PM
Dates	Start Date	Insert	New Registration			1/3/2022 2:03 PM
Terminations	Termination Comments	Insert	New Registration			1/3/2022 2:03 PM
Terminations	Termination Date	Insert	New Registration			1/3/2022 2:03 PM
Terminations	Termination Effective Date	Insert	New Registration			1/3/2022 2:03 PM
Terminations	Termination Reason	Insert	New Registration			1/3/2022 2:03 PM

340B Drug Pricing Program Database