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Covered Entity Details
Grant Number
Site ID
Medicare Provider Number
340B ID
Entity Type
Participating
Participating Start Date
Termination Date
Termination Code
Certification Date
New Record ID
Parent ID
Entity Name
Entity Sub-Division Name
Covered Entity Address
Address 1
Address 2
City
State
Zip
Second Zip
Medicaid Billing Information
Medicaid Number
NPI
Billing Information
Billing Organization
Address 1
Address 2
City
State
Zip
Second Zip
Shipping Information
Shipping Organization
Address 1
Address 2
City
State
Zip
Second Zip
Contact Information
Contact Name
Contact Title
Contact Telephone
Contact Extension
Signed By Information
Signed By Name
Signed By Title
Signed By Date
Signed By Telephone
Signed By Extension
Authorizing Official Information
Authorizing Official Name
Authorizing Official Title
Authorizing Official Telephone
Authorizing Official Extension
Misc.
Rural
Entry Comments
Edit Date
Created Date
Contract Pharmacy Details
Pharmacy Name
Address 1
Address 2
Address 3
City
State
Zip
Second Zip
Contract Begin Date
Contract Approval Date
Contract Term Date
Pharmacy Comments
Contract Pharmacy Rep Information
Contract Pharmacy Rep Name
Contract Pharmacy Rep Title
Contract Pharmacy Rep Telephone
Contract Pharmacy Rep Extension
HHS Privacy Policy Notice
OMB Number: 0915-0327, Expiration: 10/31/2015
U.S. Department of Health and Human Services (HHS)
Health Resources and Services Administration (HRSA)
Office of Pharmacy Affairs (OPA) - 340B Program
May 25, 2013
10:10 AM ET
Questions, Comments, or Suggestions
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ApexusAnswers@340bpvp.com
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1 - 888 - 340 - 2787