Annual Recertification for Other Entities

340B Drug Pricing Program Forms

Recertification Information

Annual Recertification for Other Entities

OMB: 0915-0327

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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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File Typeapplication/msword
File TitleThis is an example of a screenshot of the 340B public database and the information that covered entities would need to certify d
AuthorHrsa
Last Modified ByHrsa
File Modified2009-08-14
File Created2009-08-14

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