Form 1 8 RW Recert

OPA 340B Database - (v5.2.2.2 - UAT)

1 of 2

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Covered Entity Details
340B ID:

RWI99999

Entity Name: TEST GRANTEE
Entity Sub-Division Name:
Medicare Provider Number:

Entity Type: Ryan White Part A
Grant Number: H99XX99999

Covered Entity Address
Main Address (PO Box Not Allowed)
1 TEST STREEET
TEST, AL 99999
Billing Address Same as Main
Shipping Address Same as Main

Covered Entity Date Information
Continue Undo
Registration Date:
Participating Approval Date

12/1/2004

Participating Start Date:
Termination Reason:
Termination Date:
The date the entity became ineligible:
Last date that 340B drugs were or will be
purchased under this 340B ID:
Termination Comments:

Medicaid Billing
Medicaid Billing Information
You must answer the following question regarding Medicaid Billing:
Will you bill Medicaid for drugs purchased at 340B drug price?

Yes

No

8/22/2013 7:46 AM

OPA 340B Database - (v5.2.2.2 - UAT)

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Contact Information
Authorizing Official
Name:
Title:
Phone:
Email:

Test User
Chief Executive Officer
999-999-9999 Ext:
[email protected]

Make Primary Contact Information same as Authorizing Official

Primary Contact
Name:
Title:
Phone:
Email:

Test User
Chief Executive Officer
999-999-9999 Ext:
[email protected]

HHS Privacy Policy Notice
U.S. Department of Health and Human Services (HHS)
Health Resources and Services Administration (HRSA)
Office of Pharmacy Affairs (OPA) - 340B Program

OMB Number: 0915-0327, Expiration: 10/31/2015

August 22, 2013
7:46 AM ET

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8/22/2013 7:46 AM