Hospital Annual Recertification

This is an example of a screenshot of the 340B public database and confirming their administration information that is stored in the 340B public database.the information that hospitals would need to certify during the electronic recertification process.

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8/14/2009 12:54:00 PM

Covered Entity

Covered Entity Information

Grant/Provider Number:	090006
Entity Type:	Disproportionate Share Hospital
340B ID:	DSH090006
Entity Name:	PROVIDENCE HOSPITAL
Sub-Division Name:
Address:	1150 VARNUM STREET, NE
	WASHINGTON, District of Columbia 20017
Comments:	5/1/08-REVISED MEDICAID # (WAS 0293340)

Contract Pharmacies

Link to Pharmacy	Name	Address	Address (con't)	City	State	Zip	Begin Date	Termination Date
Link	WELLINGTON APOTHECARY	1160 VARNUM STREET, NE		WASHINGTON	DC	20017	03/14/2008

340B Program Information
Rural:	No
Participating:	YES
Participating Start Date:	7/1/2003
Termination Date:
Terminated(Previous) 340B ID:	DSH20017
Medicaid Provider Number/NPI:	029833400 - (DC)
Alternative Methods:	NO

Covered Entity Authorizing Official
Signed:
Title:	PRESIDENT/CEO
Date Signed:
Phone:	202-

Covered Entity Contact Information
Name:
Title:	SENIOR VP/FINANCE
Phone:	202-

Edit User:	NSingh
Edit Date:	5/1/2008

Other Related 340B Entities

Detail	340B ID	Entity Name	Sub-Division Name	Address	Address (con't)	City	State	Start Date	Term Date
Detail	DSH20017	PROVIDENCE HOSPITAL		1150 VARNUM STREET, NE		WASHINGTON	DC	07/01/2003	07/01/2008

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