Covered Entity Details

DSH150021FE Parkview Hospital (Terminated) - information as of 6/19/2025 11:52:54 PM

Main Details

Name

Parkview Hospital

Subdivision Name

LIMA ROAD CLINIC LAB - Lab

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH150021FE

Medicare Provider Number

150021

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

7/2/2023

Participating Start Date

10/1/2023

Participating Approval Date

7/18/2023

Last Recertification Date

8/14/2024

Termination Date
Termination Reason

4/1/2025
Never implemented the 340B Program

Contacts

Authorizing Official

Parkview Health System
Stanton Risser, Assoc Chief Financial Officer
(260) 266-9313

Primary Contact

Parkview Health
Stephanie Dickmeyer, 340B Program Supervisor
(260) 266-4408

Addresses

Street Address

11055 Twin Creeks Cove
Fort Wayne, IN 46845

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
IN	100268480A	1366407603
OH	6723282	1366407603
MI		1366407603

Shipping Addresses

Shipping Address 1

Parkview Regional Medical Center Pharmacy
11109 Parkview Plaza Drive
Fort Wayne, IN 46845

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
DSH150021AA	Child	DSH	Parkview Hospital	PRMC WOMENS HEALTH / Rehab-Physical Therapy	11104 Parkview Circle Dr STE 50	Fort Wayne	IN	Terminated
DSH150021AB	Child	DSH	PARKVIEW HOSPITAL	HOSPICE FORT WAYNE	1900 Carew St. Ste 6	Fort Wayne	IN	Terminated
DSH150021AC	Child	DSH	PARKVIEW HOSPITAL	HOME CARE FORT WAYNE	1900 Carew St. Ste 6	Fort Wayne	IN	Terminated
DSH150021AD	Child	DSH	Parkview Hospital	PVH Interventional Radiology	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AE	Child	DSH	Parkview Hospital	PVH REHAB PEDS ST OP	3439 Hobson Road	Fort Wayne	IN	Terminated
DSH150021AF	Child	DSH	Parkview Hospital	REHAB PEDS OT OP	3439 Hobson Road	FORT WAYNE	IN	Terminated
DSH150021AG	Child	DSH	Parkview Hospital	PVH REHAB PEDS PT OP	3439 Hobson Road	FORT WAYNE	IN	Terminated
DSH150021AH	Child	DSH	PARKVIEW HOSPITAL	RANDALLIA ECHO	2231 Carew St	FORT WAYNE	IN	Terminated
DSH150021AJ	Child	DSH	Parkview Hospital	Anticoagulation clinic / ATU	2231 CAREW ST	Fort Wayne	IN	Terminated
DSH150021AK	Child	DSH	Parkview Hospital	PVH REHAB / PHYSICAL THERAPY	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AL	Child	DSH	Parkview Hospital	PVH RESPIRATORY	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AM	Child	DSH	Parkview Hospital	FWNV1 CT	3909 New Vision Drive	FORT WAYNE	IN	Terminated
DSH150021AN	Child	DSH	Parkview Hospital	FWNV1 MRI	3909 New Vision Drive	FORT WAYNE	IN	Active
DSH150021AP	Child	DSH	PARKVIEW HOSPITAL	FORT WAYNE MRI	2110 Carew St	Fort Wayne	IN	Terminated
DSH150021AQ	Child	DSH	Parkview Hospital	PVH PREP/RECOVERY	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AR	Child	DSH	Parkview Hospital	PBH INTERMEDIATE SERVICES	1720 Beacon Street	Fort Wayne	IN	Terminated
DSH150021AS	Child	DSH	Parkview Hospital	PVH Treadmill Stress Test	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AT	Child	DSH	Parkview Hospital	PVH Pulmonary Function Test	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AU	Child	DSH	Parkview Hospital	PVH Rehab/Speech Therapy	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AV	Child	DSH	Parkview Hospital	PVH Rehab/Occupational Therapy	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AW	Child	DSH	Parkview Hospital	PVH Rehab/Physical Therapy	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021AX	Child	DSH	Parkview Hospital	PVH OP INFUSION-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AY	Child	DSH	Parkview Hospital	PVH EMERGENCY DEPARTMENT	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021AZ	Child	DSH	PARKVIEW HOSPITAL	PRMC / Nuclear Medicine Outpatient Service Center	11109 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021B	Child	DSH	Parkview Hospital	FWINV CT	8028 CARNEGIE BLVD STE 700	FORT WAYNE	IN	Terminated
DSH150021BA	Child	DSH	PARKVIEW HOSPITAL	PRMC / MRI Outpatient Services	11109 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021BB	Child	DSH	PARKVIEW HOSPITAL	PVH Continuing Care Center	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021BC	Child	DSH	PARKVIEW HOSPITAL	CT Outpatient Services Center / CT	11109 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021BD	Child	DSH	PARKVIEW HOSPITAL	Parkview Regional Medical Center / Endoscopy	11109 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021BE	Child	DSH	PARKVIEW HOSPITAL	Parkview Regional Medical Center / Rehab-Speech Therapy	11109 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021BF	Child	DSH	PARKVIEW HOSPITAL	Parkview Regional Medical Center / Rehab-Occupational Therapy	11109 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021BG	Child	DSH	PARKVIEW HOSPITAL	PARKVIEW REGIONAL MEDICAL CENTER REHAB / Physical Therapy	11109 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021BH	Child	DSH	Parkview Hospital	FWINV ECHOCARDIOGRAPHY	8028 Carnegie Blvd STE 700	FORT WAYNE	IN	Terminated
DSH150021BJ	Child	DSH	Parkview Hospital	PCI OP Infusion-Observation Beds	11050 Parkview Circle Drive STE 3A	Fort Wayne	IN	Active
DSH150021BK	Child	DSH	Parkview Hospital	PVH CAREW MEDSURG-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021BL	Child	DSH	Parkview Hospital	PVH ICU-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021BM	Child	DSH	Parkview Hospital	PVH Clinical Decision Unit	2200 Randallia drive	Fort Wayne	IN	Terminated
DSH150021BN	Child	DSH	Parkview Hospital	PVH Family Birthing Center Procedure-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021BP	Child	DSH	PARKVIEW HOSPITAL	PVH Randallia MEDSURG	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021BQ	Child	DSH	Parkview Hospital	PVH IV Team	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021BR	Child	DSH	Parkview Hospital	PVH Family Birthing-Observation Beds	2200 Randallia Drive	Fot Wayne	IN	Active
DSH150021BS	Child	DSH	Parkview Hospital	PVH Rehab Unit-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021BT	Child	DSH	Parkview Hospital	PVH STATE MEDSURG-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021BU	Child	DSH	Parkview Hospital	PRMC Center on Aging and Health	11104 Parkview Circle Dr STE 40	Fort Wayne	IN	Terminated
DSH150021BV	Child	DSH	Parkview Hospital	PVH Bridgeways	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021BW	Child	DSH	Parkview Hospital	PBH Youth-Observation Beds	1720 Beacon Street	Fort Wayne	IN	Active
DSH150021BX	Child	DSH	Parkview Hospital	PBH NORTH EAST SOUTH WEST-Observation Beds	1720 Beacon Street	Fort Wayne	IN	Active
DSH150021BY	Child	DSH	Parkview Hospital	PBH Assessment Center	1720 BEACON STREET	FORT WAYNE	IN	Terminated
DSH150021BZ	Child	DSH	Parkview Hospital	PRMC Ultrasound OSC	11141 Parkview Plaza Drive STE 100	Fort Wayne	IN	Active
DSH150021C	Child	DSH	Parkview Hospital	PVH CV NUCLEAR MEDICINE	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021CA	Child	DSH	Parkview Hospital	PRMC Rapid Diagnostic Unit-Observation Beds	11104 Parkview Circle Dr Suite 210	Fort Wayne	IN	Active
DSH150021CB	Child	DSH	Parkview Hospital	PVH CARDIAC REHAB	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021CC	Child	DSH	Parkview Hospital	PVH CHRONIC PAIN PARTIAL HOSPITALIZATION	2200 Randallia Drive	Fort Wayne	IN	ToBeTerminated
DSH150021CD	Child	DSH	Parkview Hospital	PCI ULTRASOUND	11050 Parkview Circle Drive STE 1C	FORT WAYNE	IN	Active
DSH150021CE	Child	DSH	Parkview Hospital	PCI CT	11050 Parkview Circle Drive STE 1C	fort wayne	IN	Active
DSH150021CF	Child	DSH	Parkview Hospital	PBH PHYSICAL THERAPY	1720 BEACON STREET	FORT WAYNE	IN	Terminated
DSH150021CG	Child	DSH	Parkview Hospital	PVH ULTRASOUND	2200 Randallia Drive	FORT WAYNE	IN	Active
DSH150021CH	Child	DSH	Parkview Hospital	PCI DIAGNOSTIC IMAGING	11050 Parkview Circle Drive	FORT WAYNE	IN	Terminated
DSH150021CJ	Child	DSH	Parkview Hospital	PRMC PHI HEART FAILURE CLINIC	11108 PARKVIEW CIRCLE DR	FORT WAYNE	IN	Terminated
DSH150021CK	Child	DSH	Parkview Hospital	PBH REHAB/OCCUPATIONAL THERAPY	1720 BEACON STREET	FORT WAYNE	IN	Terminated
DSH150021CL	Child	DSH	Parkview Hospital	PRMC PREOP CLINIC OSC-Observation Beds	11143 Parkview Plaza Drive Suite 110	FORT WAYNE	IN	Active
DSH150021CM	Child	DSH	Parkview Hospital	PVH HEART FAILURE CLINIC	2200 Randallia Drive	FORT WAYNE	IN	Terminated
DSH150021CN	Child	DSH	Parkview Hospital	PVH CATH LAB	2200 Randallia Drive	FORT WAYNE	IN	ToBeTerminated
DSH150021CP	Child	DSH	Parkview Hospital	PVH SUPPORTIVE CARE UNIT	2200 Randallia Drive	FORT WAYNE	IN	Terminated
DSH150021CQ	Child	DSH	Parkview Hospital	PVH SLEEP LAB	2200 Randallia Drive	FORT WAYNE	IN	Active
DSH150021CR	Child	DSH	Parkview Hospital	PVH INFECTIOUS DISEASE	2231 CAREW ST	FORT WAYNE	IN	Active
DSH150021CS	Child	DSH	Parkview Hospital	PVH HOLTER MON AND EVENT RECORDING	2200 Randallia Drive	FORT WAYNE	IN	Terminated
DSH150021CT	Child	DSH	Parkview Hospital	PRMC EEG PEDS	11123 PARKVIEW PLAZA DR STE 202	FORT WAYNE	IN	Terminated
DSH150021CU	Child	DSH	Parkview Hospital	PRMC INFECTIOUS DISEASE	11104 PARKVIEW CIRCLE DR STE 440	FORT WAYNE	IN	Active
DSH150021CV	Child	DSH	Parkview Hospital	FWNV1 ULTRASOUND	3909 NEW VISION DRIVE	FORT WAYNE	IN	Active
DSH150021CW	Child	DSH	Parkview Hospital	PRMC ENDOSCOPY	11104 PARKVIEW CIRCLE DR STE 220	FORT WAYNE	IN	Active
DSH150021CX	Child	DSH	Parkview Hospital	PVH EEG	2200 Randallia Drive	FORT WAYNE	IN	Active
DSH150021CY	Child	DSH	Parkview Hospital	PREMIER SURGERY OPERATING ROOM	11141 Parkview Plaza Drive STE 200	FORT WAYNE	IN	Active
DSH150021CZ	Child	DSH	Parkview Hospital	PCI MRI	11050 Parkview Circle Drive STE 1C	FORT WAYNE	IN	Active
DSH150021D	Child	DSH	Parkview Hospital	PVH CT	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021DA	Child	DSH	Parkview Hospital	PRMC ECHO PEDS	11123 PARKVIEW PLAZA DR STE 202	FORT WAYNE	IN	Active
DSH150021DB	Child	DSH	Parkview Hospital	PRMC PEDS OP INFUSION	11123 PARKVIEW PLAZA DR STE 202	FORT WAYNE	IN	Active
DSH150021DC	Child	DSH	Parkview Hospital	PVH DIAGNOSTIC IMAGING	2200 Randallia Drive	FORT WAYNE	IN	Terminated
DSH150021DD	Child	DSH	Parkview Hospital	PRMC DIAGNOSTIC IMAGING OSC	11141 PARKVIEW PLAZA DRIVE STE 200	FORT WAYNE	IN	Terminated
DSH150021DE	Child	DSH	Parkview Hospital	PBH NUTRITION	1720 BEACON STREET	FORT WAYNE	IN	Terminated
DSH150021DF	Child	DSH	Parkview Hospital	PCI MAMMOGRAPHY	11050 Parkview Circle Drive STE 4A	FORT WAYNE	IN	Active
DSH150021DG	Child	DSH	Parkview Hospital	PRMC RHEUMATOLOGY	11143 Parkview Plaza Drive STE 200	FORT WAYNE	IN	Active
DSH150021DH	Child	DSH	Parkview Hospital	PREMIER SURGERY PACU	11141 PARKVIEW PLAZA DRIVE STE 200	FORT WAYNE	IN	Active
DSH150021DJ	Child	DSH	Parkview Hospital	PVH EKG	2200 Randallia Drive	FORT WAYNE	IN	Active
DSH150021DK	Child	DSH	Parkview Hospital	FWINV DIAGNOSTIC IMAGING	8028 CARNEGIE BLVD STE 700	FORT WAYNE	IN	Terminated
DSH150021DL	Child	DSH	Parkview Hospital	PRMC HOLTER MONITOR PEDS	11123 PARKVIEW PLAZA DR STE 202	FORT WAYNE	IN	Terminated
DSH150021DM	Child	DSH	Parkview Hospital	PREMIER SURGERY PREP/RECOVERY	11141 PARKVIEW PLAZA DRIVE STE 200	FORT WAYNE	IN	Active
DSH150021DN	Child	DSH	Parkview Hospital	PVH ENGLISH PROGRESSIVE-Observation Beds	2200 Randallia Drive	FORT WAYNE	IN	Active
DSH150021DP	Child	DSH	Parkview Hospital	FWNV1 DIAGNOSTIC IMAGING	3909 NEW VISION DR	FORT WAYNE	IN	Terminated
DSH150021DQ	Child	DSH	Parkview Hospital	PVH 2 SURGICAL-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021DR	Child	DSH	Parkview Hospital	PRMC EEG OSC	11141 PARKVIEW PLAZA DR	Fort Wayne	IN	Terminated
DSH150021DS	Child	DSH	Parkview Hospital	PRMC W & C ADVANCED PERINATAL CARE CENTER-Observation Beds	11123 PARKVIEW PLAZA DR STE 204	FORT WAYNE	IN	Active
DSH150021DT	Child	DSH	Parkview Hospital	PVH 4 Medical-Observation Beds	2200 Randallia Drive	FORT WAYNE	IN	Active
DSH150021DU	Child	DSH	Parkview Hospital	PVH MEDSURGE EXTENDED - MedSurge Extended	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021DV	Child	DSH	Parkview Hospital	PVH PULMONARY REHAB - Pulm Rehab	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021DW	Child	DSH	Parkview Hospital	PVH Ostomy Clinic - Clinic	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021DX	Child	DSH	Parkview Hospital	PVH 7 MEDICAL-Outpatient Observation Beds - Clinic	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021DY	Child	DSH	Parkview Hospital	PVH 5 MEDICAL-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021DZ	Child	DSH	Parkview Hospital	PVH SURGE MEDSURG EXTENDED-Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021E	Child	DSH	Parkview Hospital	PVH NUCLEAR MEDICINE	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021EA	Child	DSH	Parkview Hospital	PVH Lab - Lab	2200 Randallia Dr	Fort Wayne	IN	Terminated
DSH150021EB	Child	DSH	Parkview Hospital	PRMC Lab - OSC	11141 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021EC	Child	DSH	Parkview Hospital	PARKVIEW REG MED CENTER LAB - PCI Lab	11050 PARKVIEW CIRCLE DR	FORT WAYNE	IN	Terminated
DSH150021ED	Child	DSH	Parkview Hospital	PRMC MRI OSC - Radiology	11141 Parkview Plaza Drive STE 100	Fort Wayne	IN	Active
DSH150021EE	Child	DSH	Parkview Hospital	PRMC NUCLEAR MEDICINE OSC - Radiology	11141 Parkview Plaza Drive STE 100	Fort Wayne	IN	Active
DSH150021EF	Child	DSH	Parkview Hospital	PRMC CT OSC - Radiology	11141 Parkview Plaza Drive STE 100	Fort Wayne	IN	Active
DSH150021EG	Child	DSH	Parkview Hospital	FWNV1 DIAG IMAGING - Radiology	3909 New Vision Dr	Fort Wayne	IN	Terminated
DSH150021EH	Child	DSH	Parkview Hospital	PRMC LAB WAUSEON 725 SHOOP - Lab	725 S Shoop Ave	Wauseon	OH	Terminated
DSH150021EJ	Child	DSH	Parkview Hospital	PBH IOP CD - Partial Hospitalization	1720 Beacon Street	Fort Wayne	IN	Active
DSH150021EK	Child	DSH	Parkview Hospital	NORTH CLINTON 5110 LAB - Lab	5110 N. Clinton	Fort Wayne	IN	Terminated
DSH150021EL	Child	DSH	Parkview Hospital	FWINV PEDIATRIC ECHOCARDIOGRAPHY - Radiology	8028 Carnegie Blvd, Suite 700	Fort Wayne	IN	Active
DSH150021EM	Child	DSH	Parkview Hospital	FWLM DIAG IMAGING - Radiology	8911 Liberty Mills Rd, Ste 200	Fort Wayne	IN	Terminated
DSH150021EN	Child	DSH	Parkview Hospital	PRMC LAB MONTPELIER - Lab	935 Snyder Ave	Montpelier	OH	Terminated
DSH150021EP	Child	DSH	Parkview Hospital	NHMR DIAG IMAGING - Radiology	1331 Minnich Road	New Haven	IN	Terminated
DSH150021EQ	Child	DSH	Parkview Hospital	PRMC EEG OP - Electroencephalography	11104 Parkview Circle Dr Suite 040	Fort Wayne	IN	Active
DSH150021ER	Child	DSH	Parkview Hospital	PVH HOLTER MON AND EVENT RECORDING - Echocardiology	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021ES	Child	DSH	Parkview Hospital	PVH PULMONARY REHAB - Respiratory Therapy	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021ET	Child	DSH	Parkview Hospital	ST JOE CTR LAB - Lab	5693 YMCA Park Drive West	Fort Wayne	IN	Terminated
DSH150021EU	Child	DSH	Parkview Hospital	FWLM LAB - Lab	8911 Liberty Mills Rd, Ste 200	Fort Wayne	IN	Terminated
DSH150021EV	Child	DSH	Parkview Hospital	CAREW MEDICAL PARK LAB - Lab	1818 Carew Street	Fort Wayne	IN	Terminated
DSH150021EW	Child	DSH	Parkview Hospital	PBH IOP MH - Observation Beds	1720 Beacon Street	Fort Wayne	IN	Active
DSH150021EX	Child	DSH	Parkview Hospital	FWNV1 LAB - Lab	3909 New Vision Dr	Fort Wayne	IN	Terminated
DSH150021EY	Child	DSH	Parkview Hospital	PVH REHAB PEDS NUTRITION - Nutrition Support	3439 Hobson Road	Fort Wayne	IN	Active
DSH150021EZ	Child	DSH	Parkview Hospital	WAYNEDALE TEMPLE LAB - Lab	8607 Temple Dr.	Fort Wayne	IN	Terminated
DSH150021F	Child	DSH	Parkview Hospital	PVH MRI	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021FA	Child	DSH	Parkview Hospital	PRMC LAB ARCHBOLD - Lab	121 Westfield Dr	Archbold	OH	Terminated
DSH150021FB	Child	DSH	Parkview Hospital	PARKVIEW NEUROSCIENCES MULTISPECIALTY CLINIC - Neuro Rehab	11104 Parkview Circle Dr Suite 040	Fort Wayne	IN	Active
DSH150021FC	Child	DSH	Parkview Hospital	PVH 6 EAST - Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021FD	Child	DSH	Parkview Hospital	PRMC DIABETES ED - Clinic	11143 Parkview Plaza Dr, Suite 110	Fort Wayne	IN	Active
DSH150021FE	Child	DSH	Parkview Hospital	LIMA ROAD CLINIC LAB - Lab	11055 Twin Creeks Cove	Fort Wayne	IN	Terminated
DSH150021FF	Child	DSH	Parkview Hospital	PVH DIAG IMAGING - Radiology	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021FG	Child	DSH	Parkview Hospital	PRMC DIAG IMAGING OSC - Radiology	11141 Parkview Plaza Drive,Entrance 3	Fort Wayne	IN	Terminated
DSH150021FH	Child	DSH	Parkview Hospital	PVH ED OUTPATIENTS - Emergency Infusion	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021FJ	Child	DSH	Parkview Hospital	PRMC MOB2 OBGYN LAB - Lab	11123 Parkview Plaza Dr	Fort Wayne	IN	Terminated
DSH150021FK	Child	DSH	Parkview Hospital	FWINV LAB - Lab	8028 Carnegie Blvd, Suite 160	Fort Wayne	IN	Terminated
DSH150021FL	Child	DSH	Parkview Hospital	PRMC PEDS DEV CARE CENTER OSC - Clinic	11141 Parkview Plaza Drive STE 210	Fort Wayne	IN	Active
DSH150021FM	Child	DSH	Parkview Hospital	GRABILL MAIN LAB - Lab	13430 Main Street	Grabill	IN	Terminated
DSH150021FN	Child	DSH	Parkview Hospital	PVH 3 STATE - Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021FP	Child	DSH	Parkview Hospital	FWINV DIAG IMAGING - Radiology	8028 Carnegie Blvd, Suite 700	Fort Wayne	IN	Terminated
DSH150021FQ	Child	DSH	Parkview Hospital	PCI DIAG IMAGING - Radiology	11050 Parkview Circle, Entrance 12	Fort Wayne	IN	Terminated
DSH150021FR	Child	DSH	Parkview Hospital	PRMC LAB BRYAN - Lab	442 West High Street	Bryan	OH	Terminated
DSH150021FS	Child	DSH	Parkview Hospital	NHMR LAB - Lab	1331 Minnich Road	New Haven	IN	Terminated
DSH150021FT	Child	DSH	Parkview Hospital	PRMC PEDIATRIC HEMATOLOGY ONCOLOGY - Observation Beds	11104 Parkview Circle Dr Suite 050	Fort Wayne	IN	Active
DSH150021FU	Child	DSH	Parkview Hospital	PVH 6 SOUTH - Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021FV	Child	DSH	Parkview Hospital	PRMC PEDIATRIC HEMATOLOGY ONCOLOGY INFUSION - Lab	11104 Parkview Circle Dr Suite 050	Fort Wayne	IN	Active
DSH150021FW	Child	DSH	Parkview Hospital	PFCI ONC THORACIC LUNG - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021FX	Child	DSH	Parkview Hospital	PSW PFCI UPPER AND LOWER GI - GASTROENTEROLOGY	8202 Glencarin Blvd Suite 230	Fort Wayne	IN	Active
DSH150021FY	Child	DSH	Parkview Hospital	PSW MAMMOGRAPHY - IMAGING	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021FZ	Child	DSH	Parkview Hospital	PFCI REHAB OT OP HOD - Oncology	11050 Parkview Circle	Fort Wayne	IN	ToBeTerminated
DSH150021G	Child	DSH	PARKVIEW HOSPITAL	PVH EMERGENCY DEPT	2200 Randallia Dr	Fort Wayne	IN	Terminated
DSH150021GA	Child	DSH	Parkview Hospital	PFCI PULMONOLOGY - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021GB	Child	DSH	Parkview Hospital	PSW DIAG IMAGING - IMAGING	8202 GLENCARIN BLVD	Fort Wayne	IN	Terminated
DSH150021GC	Child	DSH	Parkview Hospital	PSW RESPIRATORY - RESPIRATORY THERAPY	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021GD	Child	DSH	Parkview Hospital	PFCI ONC GENITOURINARY - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021GE	Child	DSH	Parkview Hospital	PRMC NEURO SURGERY - Neurology	11104 PARKVIEW CIRCLE DR STE 110	Fort Wayne	IN	Active
DSH150021GF	Child	DSH	Parkview Hospital	GLENCARIN LAB - Laboratory	8233 Glencarin Blvd	Fort Wayne	IN	Terminated
DSH150021GG	Child	DSH	Parkview Hospital	PFCI ONC SARCOMA - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021GH	Child	DSH	Parkview Hospital	PSW ECHO - RADIOLOGY-DIAGNOSTIC	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021GJ	Child	DSH	Parkview Hospital	PFCI ONC MEDICAL ONCOLOGY/HEMATOLOGY - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021GK	Child	DSH	Parkview Hospital	PRMC NEUROINTERVENTION - Neurology	11104 PARKVIEW CIRCLE DR STE 110	Fort Wayne	IN	Active
DSH150021GL	Child	DSH	Parkview Hospital	PSW MRI - IMAGING	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021GM	Child	DSH	Parkview Hospital	PSW STRESS TREADMILL - RESPIRATORY THERAPY	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021GN	Child	DSH	Parkview Hospital	PSW ENDOCRINOLOGY - Endocrinology	8202 Glencarin Blvd Suite 230	Fort Wayne	IN	Active
DSH150021GP	Child	DSH	Parkview Hospital	PSW CT - IMAGING	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021GQ	Child	DSH	Parkview Hospital	PFCI ONC UPPER AND LOWER GI - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021GR	Child	DSH	Parkview Hospital	PRMC OSC Endocrinology - Endocrinology	11141 PARKVIEW PLAZA DRIVE STE 310	Fort Wayne	IN	Active
DSH150021GS	Child	DSH	Parkview Hospital	PFCI REHAB ST OP - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021GT	Child	DSH	Parkview Hospital	PSW PFCI GYN - Oncology	8202 Glencarin Blvd Suite 230	Fort Wayne	IN	Active
DSH150021GU	Child	DSH	Parkview Hospital	PFCI ONC GYN - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021GV	Child	DSH	Parkview Hospital	PSW RHEUMATOLOGY - RHEUMATOLOGY	8202 Glencarin Blvd Suite 230	Fort Wayne	IN	Active
DSH150021GW	Child	DSH	Parkview Hospital	PSW PULMONARY FUNCTION TEST - RESPIRATORY THERAPY	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021GX	Child	DSH	Parkview Hospital	PFCI ONC HIGH RISK - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021GY	Child	DSH	Parkview Hospital	PSW GI - GASTROENTEROLOGY	8202 Glencarin Blvd Suite 230	Fort Wayne	IN	Active
DSH150021GZ	Child	DSH	Parkview Hospital	PSW NEURO - Neurology	8202 Glencarin Blvd Suite 230	Fort Wayne	IN	Active
DSH150021H	Child	DSH	Parkview Hospital	PVH PACU	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021HA	Child	DSH	Parkview Hospital	PSW ULTRASOUND - IMAGING	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021HB	Child	DSH	Parkview Hospital	ELECTRIC WORKS LAB - Laboratory	1660 Broadway St Suite 165	Fort Wayne	IN	Terminated
DSH150021HC	Child	DSH	Parkview Hospital	PSW EMERGENCY DEPT - EMERGENCY	8202 GLENCARIN BLVD Suite 120	Fort Wayne	IN	Active
DSH150021HD	Child	DSH	Parkview Hospital	PSW SLEEP LAB - RESPIRATORY THERAPY	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021HE	Child	DSH	Parkview Hospital	PRMC Gastroenterology - GI	11104 Parkview Circle Dr Suite 440	Fort Wayne	IN	Active
DSH150021HF	Child	DSH	Parkview Hospital	PSW EKG - RESPIRATORY THERAPY	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021HG	Child	DSH	Parkview Hospital	PSW PFCI MEDICAL ONCOLOGY/HEMATOLOGY - Oncology	8202 GLENCARIN BLVD	Fort Wayne	IN	ToBeTerminated
DSH150021HH	Child	DSH	Parkview Hospital	PFCI ONC PALCARE - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021HJ	Child	DSH	Parkview Hospital	PRMC NEURO - Neurology	11104 PARKVIEW CIRCLE DR STE 110	Fort Wayne	IN	Active
DSH150021HK	Child	DSH	Parkview Hospital	PFCI ONC BREAST - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021HL	Child	DSH	Parkview Hospital	PFCI REHAB PT OP HOD - Oncology	11050 Parkview Circle	Fort Wayne	IN	Active
DSH150021HM	Child	DSH	Parkview Hospital	PSW LAB - Laboratory	8202 GLENCARIN BLVD	Fort Wayne	IN	Terminated
DSH150021HN	Child	DSH	Parkview Hospital	PSW PFCI BREAST - Oncology	8202 GLENCARIN BLVD	Fort Wayne	IN	ToBeTerminated
DSH150021HP	Child	DSH	Parkview Hospital	PSW URO - UROLOGY	8202 GLENCARIN BLVD	Fort Wayne	IN	ToBeTerminated
DSH150021HQ	Child	DSH	Parkview Hospital	PSW HOLTER MON AND EVENT REC - RESPIRATORY THERAPY	8202 Glencarin Blvd Suite 130	Fort Wayne	IN	Active
DSH150021HR	Child	DSH	Parkview Hospital	PBH ASSESSMENT CENTER - Psychiatry	1720 Beacon Street	Fort Wayne	IN	Active
DSH150021HS	Child	DSH	Parkview Hospital	PEDS NUTRITION DEV CARE CENTER - Nutrition	11141 Parkview Plaza Dr Suite 210	Fort Wayne	IN	Active
DSH150021HT	Child	DSH	Parkview Hospital	PRMC PEDS DEV CARE CENTER SPEECH THERAPY - Developmental and Behavioral Pediatrics	11141 PARKVIEW PLAZA DRIVE Suite 210	Fort Wayne	IN	Active
DSH150021HU	Child	DSH	Parkview Hospital	PVH OR ENDO - General Surgery	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021HV	Child	DSH	Parkview Hospital	PVH PERFUSION - Operating Room	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021HW	Child	DSH	Parkview Hospital	PVH PREOP CLINIC - Pre-Admission Testing	2200 Randallia Drive	Fort Wayne	IN	ToBeTerminated
DSH150021HX	Child	DSH	Parkview Hospital	PVH PREP/RECOVERY EXTENDED - EMERGENCY	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021HY	Child	DSH	Parkview Hospital	PVH REHAB PEDS OT OP - Occupational Therapy	3439 Hobson Road	Fort Wayne	IN	Active
DSH150021HZ	Child	DSH	Parkview Hospital	PVH REHAB PEDS PT OP - Physical Therapy	3439 Hobson Road	Fort Wayne	IN	Active
DSH150021J	Child	DSH	Parkview Hospital	PVH FLOUROSCOPY	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021JA	Child	DSH	Parkview Hospital	PVH REHAB PEDS ST OP - Speech Therapy	3439 Hobson Road	Fort Wayne	IN	Active
DSH150021JB	Child	DSH	Parkview Hospital	RUDISILL LAB - Laboratory	1007 W. Rudisill Blvd	Fort Wayne	IN	Terminated
DSH150021JC	Child	DSH	Parkview Hospital	PBH LAB - Laboratory	1720 Beacon Street	Fort Wayne	IN	Terminated
DSH150021JD	Child	DSH	Parkview Hospital	NORTH CLINTON LAB - Laboratory	5104 N. Clinton	Fort Wayne	IN	Terminated
DSH150021JE	Child	DSH	Parkview Hospital	PRMC OSC PEDS LAB - Laboratory	11141 Parkview Plaza Dr Ste 210	Fort Wayne	IN	Terminated
DSH150021JF	Child	DSH	Parkview Hospital	PRMC HOLTER MONITOR PEDS MP2 - Cardiology	11123 Parkview Plaza Dr Ste 202	Fort Wayne	IN	Active
DSH150021JG	Child	DSH	Parkview Hospital	PRMC CANCER INSTITUTE LAB - Laboratory	11104 Parkview Circle Dr.	Fort Wayne	IN	Terminated
DSH150021JH	Child	DSH	Parkview Hospital	PVH REHAB/Physical Therapy Outpatient - Physical Therapy	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021JJ	Child	DSH	Parkview Hospital	PVH LAB PARKVIEW HEART INSTITUTE - Laboratory	2200 Randallia Drive	Fort Wayne	IN	Terminated
DSH150021JK	Child	DSH	Parkview Hospital	PVH REHAB/Occupational Therapy Outpatient - Occupational Therapy	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021JL	Child	DSH	Parkview Hospital	WOODLAND PLAZA WEIGHT MANAGEMENT - Weight Management	1234 E DUPONT RD STE 1	Fort Wayne	IN	Terminated
DSH150021JM	Child	DSH	Parkview Hospital	PVH REHAB ST OP - Neuro Rehab	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021JN	Child	DSH	Parkview Hospital	PRMC 1ST FLOOR STRESS TREADMILL - Radioisotope	11108 Parkview Circle Drive	Fort Wayne	IN	Active
DSH150021JP	Child	DSH	Parkview Hospital	PRMC ULTRASOUND PHI - Radiology	11108 Parkview Circle Drive	Fort Wayne	IN	Active
DSH150021JQ	Child	DSH	Parkview Hospital	PRMC 1ST FLOOR CV NUCLEAR MEDICINE - Radiology	11108 Parkview Circle Drive	Fort Wayne	IN	Active
DSH150021JR	Child	DSH	Parkview Hospital	WOODLAND PLAZA INFECTIOUS DISEASE - Infectious Disease	1234 E DUPONT RD STE 5	Fort Wayne	IN	Active
DSH150021JS	Child	DSH	Parkview Hospital	PRMC PREMIER ENDO - Endoscopy	11141 Parkview Plaza Drive Suite 200	Fort Wayne	IN	Active
DSH150021JT	Child	DSH	Parkview Hospital	PRMC 1ST FLOOR PHI ECHOCARDIOGRAPHY - Radiology	11108 Parkview Circle Drive	Fort Wayne	IN	Active
DSH150021JV	Child	DSH	Parkview Hospital	PSW AAI - Allergy and Asthma	8202 Glencarin Blvd Suite 230	Fort Wayne	IN	Active
DSH150021JW	Child	DSH	Parkview Hospital	PVH CMMC - Anticoag	2231 CAREW ST	Fort Wayne	IN	Active
DSH150021JX	Child	DSH	Parkview Hospital	PRMC AAI - Allergy and Asthma	11104 PARKVIEW CIRCLE DR STE 10	Fort Wayne	IN	Active
DSH150021JY	Child	DSH	Parkview Hospital	PRMC PULMONOLOGY - Pulmonology	11104 PARKVIEW CIRCLE DR STE 410	Fort Wayne	IN	Active
DSH150021JZ	Child	DSH	Parkview Hospital	PVH REHAB UNIT 2-OBSERVATION BEDS - Rehab Observation Beds	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021K	Child	DSH	Parkview Hospital	PVH OPERATING ROOM	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021L	Child	DSH	Parkview Hospital	PVH WOUND CARE	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021M	Child	DSH	Parkview Hospital	PVH ENDOSCOPY	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021N	Child	DSH	Parkview Hospital	PVH NUTRITION	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021P	Child	DSH	PARKVIEW HOSPITAL	Medical Oncology	11143 Parkview Plaza Drive	Fort Wayne	IN	Terminated
DSH150021Q	Child	DSH	PARKVIEW HOSPITAL	Regional Cancer Center / cancer services	11141 Parkview Plaza Dr., Ste 110	Fort Wayne	IN	Terminated
DSH150021R	Child	DSH	Parkview Hospital	PCI RADIATION ONC	11050 Parkview Circle Drive STE 1A	Fort Wayne	IN	Active
DSH150021S	Child	DSH	Parkview Hospital	PVH CENTER FOR WOUND HEALING	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021T	Child	DSH	Parkview Hospital	PCI GENETIC COUNSELING	11050 Parkview Circle Drive STE 1D	Fort Wayne	IN	Terminated
DSH150021U	Child	DSH	Parkview Hospital	PVH ECHOCARDIOGRAPHY	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021V	Child	DSH	Parkview Hospital	PVH DIALYSIS	2200 Randallia Drive	Fort Wayne	IN	Active
DSH150021W	Child	DSH	PARKVIEW HOSPITAL	PVH REHAB / Occupational Therapy	2200 Randallia Dr	Fort Wayne	IN	Terminated
DSH150021X	Child	DSH	Parkview Hospital	REHAB PEDS NUTRITION	3439 Hobson Road	Fort Wayne	IN	Terminated
DSH150021Y	Child	DSH	PARKVIEW HOSPITAL	PVH REHAB / Speech Therapy	2200 Randallia Dr	Fort Wayne	IN	Terminated
DSH150021Z	Child	DSH	Parkview Hospital	PVH DIABETES ED	2200 Randallia Drive	Fort Wayne	IN	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	4/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/28/2025 12:00:00 AM	3/17/2025 7:50 AM
Details	State	Update	Termination Request	Active	To Be Terminated	3/17/2025 7:50 AM
Terminations	Termination Date	Update	Termination Request		4/1/2025 12:00:00 AM	3/17/2025 7:50 AM
Terminations	Termination Effective Date	Update	Termination Request		3/1/2025 12:00:00 AM	3/17/2025 7:50 AM
Terminations	Termination Reason	Update	Termination Request		Never implemented the 340B Program	3/17/2025 7:50 AM
Addresses	Shipping Address	Update	Change Request	Parkview Regional Medical Center 11109 Parkview Plaza Drive Fort Wayne, IN 46845	Parkview Regional Medical Center Pharmacy 11109 Parkview Plaza Drive Fort Wayne, IN 46845	11/12/2024 8:46 AM
Details	Last Recertification Date	Update	Recertification		8/14/2024 10:23:16 AM	8/14/2024 10:23 AM
Contacts	Authorizing Official	Update	Change Request	Wickens, Jeanne CFO Parkview Health 2603738407	Risser, Stanton Assoc Chief Financial Officer Parkview Health System 2602669313	7/29/2024 4:18 PM
Details	State	Update		Approved	Active	10/1/2023 12:01 AM
Contacts	Signed By	Insert	New Registration		Wickens, Jeanne CFO Parkview Health 2603738407	7/18/2023 9:19 AM
Details	340B ID	Update	New Registration		DSH150021FE	7/18/2023 9:19 AM
Details	Entity Name	Update	New Registration	PARKVIEW HOSPITAL	Parkview Hospital	7/18/2023 9:19 AM
Details	Entity Subname	Update	New Registration	LIMA ROAD CLINIC LAB	LIMA ROAD CLINIC LAB - Lab	7/18/2023 9:19 AM
Dates	Participating Approval Date	Update	New Registration		7/18/2023 9:19:44 AM	7/18/2023 9:19 AM
Details	State	Update	New Registration	Pending	Approved	7/18/2023 9:19 AM
Dates	Signed By Date	Update	New Registration		7/5/2023 8:58:12 AM	7/18/2023 9:19 AM
Dates	Start Date	Update	New Registration		10/1/2023 12:00:00 AM	7/18/2023 9:19 AM
Addresses	Main Address	Insert	New Registration		11055 Twin Creeks Cove Fort Wayne, IN 46845	7/2/2023 8:20 AM
Addresses	Shipping Address	Insert	New Registration		Parkview Regional Medical Center 11109 Parkview Plaza Drive Fort Wayne, IN 46845	7/2/2023 8:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/2/2023 8:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100268480A	7/2/2023 8:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		IN	7/2/2023 8:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/2/2023 8:20 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		6723282	7/2/2023 8:20 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		OH	7/2/2023 8:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366407603	7/2/2023 8:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		IN	7/2/2023 8:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366407603	7/2/2023 8:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		MI	7/2/2023 8:20 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366407603	7/2/2023 8:20 AM
Medicaid Billing	NPI: State	Insert	New Registration		OH	7/2/2023 8:20 AM
Contacts	Authorizing Official	Insert	New Registration		Wickens, Jeanne CFO Parkview Health 2603738407	7/2/2023 8:20 AM
Contacts	Primary Contact	Insert	New Registration		Dickmeyer, Stephanie 340B Program Supervisor Parkview Health 2602664408	7/2/2023 8:20 AM
Details	Assistance Received From Date	Insert	New Registration			7/2/2023 8:20 AM
Details	Assistance Received To Date	Insert	New Registration			7/2/2023 8:20 AM
Details	Last Recertification Date	Insert	New Registration			7/2/2023 8:20 AM
Details	Grant Number	Insert	New Registration			7/2/2023 8:20 AM
Details	340B ID	Insert	New Registration			7/2/2023 8:20 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/2/2023 8:20 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/2/2023 8:20 AM
Details	Medicare Provider Number	Insert	New Registration		150021	7/2/2023 8:20 AM
Details	Entity Name	Insert	New Registration		PARKVIEW HOSPITAL	7/2/2023 8:20 AM
Details	NOFO Number	Insert	New Registration			7/2/2023 8:20 AM
Details	Program Code	Insert	New Registration		DSH	7/2/2023 8:20 AM
Details	Entity Subname	Insert	New Registration		LIMA ROAD CLINIC LAB	7/2/2023 8:20 AM
Dates	Participating Approval Date	Insert	New Registration			7/2/2023 8:20 AM
Details	State	Insert	New Registration		Pending	7/2/2023 8:20 AM
Dates	Registration Date	Insert	New Registration		7/2/2023 8:20:31 AM	7/2/2023 8:20 AM
Dates	Signed By Date	Insert	New Registration			7/2/2023 8:20 AM
Dates	Start Date	Insert	New Registration			7/2/2023 8:20 AM
Terminations	Termination Comments	Insert	New Registration			7/2/2023 8:20 AM
Terminations	Termination Date	Insert	New Registration			7/2/2023 8:20 AM
Terminations	Termination Effective Date	Insert	New Registration			7/2/2023 8:20 AM
Terminations	Termination Reason	Insert	New Registration			7/2/2023 8:20 AM