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DSH490045A PRINCE WILLIAM HOSPITAL DBA NOVANT HEALTH PRINCE WILLIAM MEDICAL (Terminated)
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Main Details
Name
PRINCE WILLIAM HOSPITAL DBA NOVANT HEALTH PRINCE WILLIAM MEDICAL
Subdivision Name
NHUVA O/P ATC - Outpatient Addiction Treatment Center
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH490045A
Medicare Provider Number
490045
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/2/2018
Participating Start Date
10/1/2018
Participating Approval Date
7/11/2018
Last Recertification Date
Termination Date
Termination Reason
10/1/2019
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
Novant Health
Geoffrey Gardner, SVP Finance
(336) 718-2078
Primary Contact
Novant Health
Elizabeth Anne Corazzo, Manager Pharmacy 340B
(336) 277-0301
Addresses
Street Address
8680 Hospital Way
Manassas, VA 20110
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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May 2025
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