Annual Recertificaion for STD & TB

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 covered entities would need to certify during the electronic recertification process.

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8/14/2009 12:39:59 PM

Covered Entity

Covered Entity Information

Grant/Provider Number:	H80CS00067
Entity Type:	Consolidated Health Center Program
340B ID:	CH030130
Entity Name:	PARK WEST HEALTH SYSTEM, INC.
Sub-Division Name:
Address:	3319 WEST BELVEDERE AVENUE
	BALTIMORE, Maryland 21215
Comments:	3/11/08 CORRECTED ENT NAME (WAS PARK WEST MEDICAL SYSTEMS, INC.)

340B Program Information
Funding Streams:	CH
Participating:	YES
Participating Start Date:	12/1/1992
Termination Date:
Medicaid Provider Number/NPI:	33291 - (MD)
Alternative Methods:	NO

Covered Entity Authorizing Official
Signed:
Title:	CEO
Date Signed:
Phone:	410-

Covered Entity Contact Information
Name:
Title:	CEO
Phone:	410-

Edit User:	SLChen
Edit Date:	3/11/2008

Children Entities

Detail	340B ID	Entity Name	Sub-Division Name	Address	Address (con't)	City	State	Start Date	Term Date
Detail	CH03013C	PARK WEST HEALTH SYSTEM, INC.		5101 LANIER AVE.		BALTIMORE	MD	04/01/2008
Detail	CH03013B	PARK WEST HEALTH SYSTEM, INC.	PLAZA SITE	4120 PATTERSON AVENUE		BALTIMORE	MD	12/01/1992
Detail	CH03013D	PARK WEST HEALTH SYSTEM, INC.	PARK WEST HLTH SYS-PARK HEIGHTS	4151 PARK HEIGHTS AVE.		BALTIMORE	MD	04/01/2008

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