Covered Entity Details

CH04170AC COLLIER HEALTH SERVICES INC (Active) - information as of 4/30/2025 10:47:28 PM

Main Details

Name

COLLIER HEALTH SERVICES INC

Subdivision Name

Healthcare Network - Mobile Outreach 1

Type

HRSA-Funded Health Center

Site ID

BPS-H80-038624

340B ID

CH04170AC

Grant Number

H80CS00735

Additional Details

Current Program Status

Active

Registration Date

5/29/2024

Participating Start Date

7/1/2024

Participating Approval Date

6/11/2024

Last Recertification Date

2/18/2025

Contacts

Authorizing Official

Collier Health Services, Inc., d/b/a Healthcare Network
John Fletcher, Chief Operating Officer & General Counsel
(239) 658-3060

Primary Contact

Collier Health Services, Inc.
Martine Woolley, Vice President of Pharmacy
(239) 658-3030

Addresses

Street Address

1454 Madison Ave W
Immokalee, FL 34142-2200

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
FL	029152824,029152825	1447099106,1255170916

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02542	7301 RADIO ROAD	NAPLES	FL	34104	11/13/2024	01/01/2025			01/01/2025

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH041700	Active	Admin	COLLIER HEALTH SERVICES, INC.	COLLIER HEALTH SERVICES, INC.	1454 Madison Ave W	Immokalee	FL
CH04170A	Terminated	BPS-H80-030431	COLLIER HEALTH SERVICES, INC.	Nichols Community Health Center	12655 Collier Blvd	Naples	FL
CH04170AA	Active	BPS-H80-038148	COLLIER HEALTH SERVICES INC	Healthcare Network Cordero Pediatrics	1090 6th Ave N	Naples	FL
CH04170AB	Active	BPS-H80-038514	COLLIER HEALTH SERVICES INC	Healthcare Network North (Veterans Park)	1845 Veterans Park Dr	Naples	FL
CH04170AC	Active	BPS-H80-038624	COLLIER HEALTH SERVICES INC	Healthcare Network - Mobile Outreach 1	1454 Madison Ave W	Immokalee	FL
CH04170AD	Active	BPS-H80-039042	COLLIER HEALTH SERVICES INC	Healthcare Network Manatee Middle	1920 Manatee Rd	Naples	FL
CH04170AE	Active	BPS-H80-039161	COLLIER HEALTH SERVICES INC	Healthcare Network Badra Pediatrics	9160 Galleria Ct	Naples	FL
CH04170AF	Active	BPS-H80-039566	COLLIER HEALTH SERVICES INC	Healthcare Network Community Medical Care Center	125 Boston Ave	Immokalee	FL
CH04170AG	Active	BPS-H80-039565	COLLIER HEALTH SERVICES INC	Healthcare Network Mobile Outreach 2	1454 Madison Ave W UNIT 4	Immokalee	FL
CH04170AH	Active	BPS-H80-039567	COLLIER HEALTH SERVICES INC	Healthcare Network Van Domelen Health Express	1454 Madison Ave W UNIT 3	Immokalee	FL
CH04170AJ	Approved	BPS-H80-039772	COLLIER HEALTH SERVICES INC	Healthcare Network Ekos Allegro	8455 Rattlesnake Hammock Rd STE CH-105	Naples	FL
CH04170B	Terminated	BPS-H80-015084	COLLIER HEALTH SERVICES, INC.	Total Women&s Care of Naples	1890 SW Health Parkway, Suite 203	Naples	FL
CH04170C	Active	BPS-H80-013952	COLLIER HEALTH SERVICES, INC.	Children's Care East	6350 DAVIS BLVD	NAPLES	FL
CH04170D	Terminated	BPS-H80-010730	COLLIER HEALTH SERVICES, INC.	Creekside Family Practice	1284 Creekside St	Naples	FL
CH04170E	Active	BPS-H80-010214	COLLIER HEALTH SERVICES, INC.	CREEKSIDE PEDIATRICS	1265 Creekside Pkwy STE 208	Naples	FL
CH04170F	Active	BPS-H80-009167	COLLIER HEALTH SERVICES, INC.	Immokalee Family Care Center	508 N 9th St	Immokalee	FL
CH04170G	Active	BPS-H80-007372	COLLIER HEALTH SERVICES, INC.	RONALD MCDONALD CARE MOBILE	1454 Madison Ave W	Immokalee	FL
CH04170H	Terminated	BPS-H80-005572	COLLIER HEALTH SERVICES, INC.	The Mike Davis Medical Center	1755 HERITAGE TRAIL	NAPLES	FL
CH04170J	Active	BPS-H80-004275	COLLIER HEALTH SERVICES, INC.	CHS-FSU Primary Care	1441 HERITAGE BLVD	IMMOKALEE	FL
CH04170K	Terminated	BPS-H80-003592	COLLIER HEALTH SERVICES, INC.	CENTRAL NAPLES PEDIATRICS	3425 10th St N	Naples	FL
CH04170L	Active	BPS-H80-002996	COLLIER HEALTH SERVICES, INC.	Countryside Dental	1749 Heritage Trail	Naples	FL
CH04170M	Active	BPS-H80-030431	COLLIER HEALTH SERVICES, INC.	Nichols Community Health Center	12655 Collier Blvd	NAPLES	FL
CH04170N	Terminated	BPS-H80-030431	COLLIER HEALTH SERVICES, INC.	GOLDEN GATE PEDIATRICS	12655 Collier Blvd	Naples	FL
CH04170P	Terminated	BPS-H80-001174	COLLIER HEALTH SERVICES, INC.	MARCO ISLAND PEDIATRICS	40 HEATHWOOD DRIVE STE F	MARCO ISLAND	FL
CH04170Q	Active	BPS-H80-017394	COLLIER HEALTH SERVICES, INC.	Health and Smiles	1454 Madison Ave W	Immokalee	FL
CH04170R	Active	BPS-H80-015787	COLLIER HEALTH SERVICES, INC.	Friendship Health Center	2355 Stanford Court	Naples	FL
CH04170S	Terminated	BPS-H80-007640	COLLIER HEALTH SERVICES, INC.	CHS University of Florida Pediatric Dental Center	7505 Grand Lely Drive	Naples	FL
CH04170T	Active	BPS-H80-005514	COLLIER HEALTH SERVICES, INC.	MARION E FETHER MEDICAL CENTER	1454 Madison Ave W	Immokalee	FL
CH04170U	Terminated	BPS-H80-017396	COLLIER HEALTH SERVICES, INC.	Dental Care Central	4077 Tamiami Trail North	Naples	FL
CH04170V	Active	BPS-H80-017201	COLLIER HEALTH SERVICES, INC.	Nichols Pediatric Center	5450 YMCA Road	Naples	FL
CH04170W	Terminated	BPS-H80-019083	COLLIER HEALTH SERVICES, INC.	Family Care DLC	6075 Bathey Ln.	Naples	FL
CH04170X	Active	BPS-H80-021572	COLLIER HEALTH SERVICES, INC.	Family Care North	1265 Creekside Pkwy Ste 206	Naples	FL
CH04170Y	Terminated	BPS-H80-022240	COLLIER HEALTH SERVICES, INC.	Children's Care West	1008 Goodlette-Frank Rd STE 100	Naples	FL
CH04170Z	Terminated	BPS-H80-037037	COLLIER HEALTH SERVICES INC	Healthcare Network Apple Pediatrics	7795 Davis Blvd, Ste 206	Naples	FL

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH041700	AMERICAN DISCOUNT PHARMACY CORP.		110 E. MAIN STREET SUITE A	IMMOKALEE	FL	34142-3395	04/01/2015	11/17/2015
CH041700	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2022
CH041700	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2022
CH041700	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2022
CH041700	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2022
CH041700	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2022
CH041700	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2022
CH041700	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2022
CH041700	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2022
CH041700	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2022
CH041700	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2022
CH041700	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/01/2022
CH041700	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/01/2024
CH041700	GENOA HEALTHCARE LLC	6075 BATHEY LANE, SUITE D-5		NAPLES	FL	34116	10/01/2017	01/15/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03248	1102 N 15TH ST	IMMOKALEE	FL	34142	04/01/2016
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05041	5585 GOLDEN GATE PKWY	NAPLES	FL	34116	10/01/2017
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 08927	8831 IMMOKALEE RD.	NAPLES	FL	34120	10/01/2017
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01807	1350 LEE BLVD	LEHIGH ACRES	FL	33936	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01816	5296 TAMIAMI TRL N	NAPLES	FL	34103	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03266	4890 TAMIAMI TR	NAPLES	FL	34112	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03677	2344 IMMOKALEE RD	NAPLES	FL	34110	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04228	5070 AIRPORT RD N	NAPLES	FL	34105	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA CVS/PHARMACY #4738	13400 IMMOKALEE ROAD	NAPLES	FL	34120	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05187	2375 VANDERBILT BEACH RD	NAPLES	FL	34109	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05375	14240 TAMIAMI TRAIL NORTH	NAPLES	FL	34110	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05787	11500 BONITA BEACH RD. SE	BONITA SPRINGS	FL	34135	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05824	2515 SHADOWLAWN DR.	NAPLES	FL	34112	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 07899	6800 COLLIER BLVD,	NAPLES	FL	34114	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 08397	7380 DAVIS BLVD	NAPLES	FL	34104	01/01/2022
CH041700	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 17433	9350 DYNASTY DR	FT MYERS	FL	33905	01/01/2022
CH04170J	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03248	1102 N 15TH ST	IMMOKALEE	FL	34142	01/01/2024
CH04170V	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05041	5585 GOLDEN GATE PKWY	NAPLES	FL	34116	01/01/2024
CH04170R	HOLIDAY CVS, L.L.C.	DBA CVS/PHARMACY #4738	13400 IMMOKALEE ROAD	NAPLES	FL	34120	01/01/2024
CH04170G	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03266	4890 TAMIAMI TR	NAPLES	FL	34112	01/01/2024	10/11/2023
CH04170G	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01807	1350 LEE BLVD	LEHIGH ACRES	FL	33936	01/01/2024
CH04170C	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03266	4890 TAMIAMI TR	NAPLES	FL	34112	01/01/2024
CH041700	JTJ MEDICAL SUPPLY, INC	DBA MAIL MEDS CLINICAL PHARMACY	2692 OAK RIDGE CT	FORT MYERS	FL	33901	10/01/2015
CH041700	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2022
CH041700	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/01/2022
CH041700	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	01/01/2022
CH041700	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	01/01/2022
CH041700	SIDDH INC	TOWN PHARMACY	107 W MAIN ST	IMMOKALEE	FL	34142-3414	10/01/2015	02/09/2017
CH041700	US SPECIALTY CARE PHARMACY		7472 S TUCSON WAY SUITE 100-B	CENTENNIAL	CO	80112-4452	04/01/2015	02/01/2016
CH041700	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/01/2023
CH041700	WAL-MART PHARMACY 10-1119	3451 TAMIAMI TRAIL EAST		NAPLES	FL	34112	04/01/2016
CH041700	WAL-MART PHARMACY 10-1957	11225 TAMIAMI TRAIL NORTH		NAPLES	FL	34110	04/01/2016
CH041700	WAL-MART PHARMACY 10-2237	2523 LEE BLVD		LEHIGH ACRES	FL	33971	04/01/2016
CH041700	WAL-MART PHARMACY 10-3417	6650 COLLIER BOULEVARD		NAPLES	FL	34114	04/01/2016
CH041700	WAL-MART PHARMACY 10-4354	5010 AIRPORT PULLING ROAD		NAPLES	FL	34105	04/01/2016
CH041700	WAL-MART PHARMACY 10-5055	9885 COLLIER BLVD		NAPLES (SE)	FL	34114	04/01/2016
CH041700	WAL-MART PHARMACY 10-5391	5420 JULIET BOULEVARD		NAPLES	FL	34109	04/01/2016
CH041700	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	01/01/2023
CH041700	WALGREEN CO	DBA: WALGREENS #10794	12955 COLLIER BLVD	NAPLES	FL	34116	04/01/2017	07/01/2017
CH041700	WALGREEN CO.	DBA: WALGREENS # 05693	1450 IMMOKALEE DRIVE	IMMOKALEE	FL	34142	07/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS # 04482	1565 AIRPORT ROAD SOUTH	NAPLES	FL	34104	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS # 04524	12780 TAMIAMI TRAIL E	NAPLES	FL	34113	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS # 05197	1800 SAN MARCO RD	MARCO ISLAND	FL	34145	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS # 05330	1100 N. COLLIER BLVD.	MARCO ISLAND	FL	34145	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS # 06071	38 HOMESTEAD RD N	LEHIGH ACRES	FL	33936-6646	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS # 06500	4290 TAMIAMI TRAILS EAST	NAPLES	FL	34112	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS # 06775	15295 COLLIER BLVD	NAPLES	FL	34119-7715	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS # 10204	2200 TAMIAMI TRL N	NAPLES	FL	34103	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS #10742	30 GOLDEN GATE BLVD W	NAPLES	FL	34120	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS #11658	4747 GOLDEN GATE PKWY	NAPLES	FL	34116	10/01/2015
CH041700	WALGREEN CO.	DBA: WALGREENS #04958	7985 AIRPORT RD N	NAPLES	FL	34109	04/01/2017
CH041700	WALGREEN CO.	DBA: WALGREENS #16052	2511 PINE RIDGE RD	NAPLES	FL	34109	04/01/2018
CH041700	WALGREEN CO.	DBA: WALGREENS # 02542	7301 RADIO ROAD	NAPLES	FL	34104	04/01/2018
CH041700	WALGREEN CO.	DBA: WALGREENS # 04167	8900 TAMIAMI TRAIL NORTH	NAPLES	FL	34108	07/01/2018
CH041700	WALGREEN CO.	DBA: WALGREENS # 02895	6029 PINE RIDGE ROAD	NAPLES	FL	34119	10/01/2018
CH041700	WALGREEN CO.	DBA: WALGREENS # 01662	4673 TAMIAMI TRL N	NAPLES	FL	34103	01/01/2022
CH041700	WALGREEN CO.	DBA: WALGREENS # 04165	28100 S. TAMIAMI TRAIL	BONITA SPRINGS	FL	34134	01/01/2022
CH04170F	WALGREEN CO.	DBA: WALGREENS # 05693	1450 IMMOKALEE DRIVE	IMMOKALEE	FL	34142	01/01/2024
CH04170E	WALGREEN CO.	DBA: WALGREENS #11658	4747 GOLDEN GATE PKWY	NAPLES	FL	34116	01/01/2024
CH04170L	WALGREEN CO.	DBA: WALGREENS # 04524	12780 TAMIAMI TRAIL E	NAPLES	FL	34113	01/01/2024
CH04170Z	WALGREEN CO.	DBA: WALGREENS #10742	30 GOLDEN GATE BLVD W	NAPLES	FL	34120	01/01/2024	04/01/2024
CH04170Q	WALGREEN CO.	DBA: WALGREENS # 06071	38 HOMESTEAD RD N	LEHIGH ACRES	FL	33936-6646	01/01/2024
CH04170X	WALGREEN CO.	DBA: WALGREENS # 04482	1565 AIRPORT ROAD SOUTH	NAPLES	FL	34104	01/01/2024
CH04170AA	WALGREEN CO.	DBA: WALGREENS #10742	30 GOLDEN GATE BLVD W	NAPLES	FL	34120	07/01/2024
CH04170AB	WALGREEN CO.	DBA: WALGREENS #10742	30 GOLDEN GATE BLVD W	NAPLES	FL	34120	01/01/2025	01/01/2025
CH04170AC	WALGREEN CO.	DBA: WALGREENS # 02542	7301 RADIO ROAD	NAPLES	FL	34104	01/01/2025
CH04170AD	WALGREEN CO.	DBA: WALGREENS # 06500	4290 TAMIAMI TRAILS EAST	NAPLES	FL	34112	01/01/2025
CH04170AB	WALGREEN CO.	DBA: WALGREENS # 06775	15295 COLLIER BLVD	NAPLES	FL	34119-7715	01/01/2025
CH041700	Walgreens #21395	Walgreens Central Fill #21395	5710 Young Pine Rd	Orlando	FL	32829	01/01/2023
CH04170AE	Walgreens #21395	Walgreens Central Fill #21395	5710 Young Pine Rd	Orlando	FL	32829	04/01/2025
CH041700	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/01/2015	03/05/2018
CH041700	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	01/01/2018
CH041700	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/01/2024
CH041700	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/01/2024
CH041700	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	01/01/2018
CH041700	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/01/2023
CH041700	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	04/01/2024
CH041700	WELLDYNERX		7472 S. TUSCON WAY SUITE 100-A	CENTENNIAL	CO	80112	04/01/2015	07/02/2015
CH041700	WELLDYNERX LLC	DBA HEALTHDYNE PHARMACY	500 EAGLES LANDING DR	LAKELAND	FL	33810	04/01/2015	07/02/2015
CH041700	WINN DIXIE PHARMACY #743	4849 GOLDEN GATE PKWY		NAPLES	FL	34116	04/01/2016	08/08/2020

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/18/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		029152824	2/18/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	2/18/2025 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/18/2025 3:14 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		029152825	2/18/2025 3:14 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	2/18/2025 3:14 PM
Details	Last Recertification Date	Update	Recertification		2/18/2025 3:14:12 PM	2/18/2025 3:14 PM
Details	State	Update		Approved	Active	7/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Fletcher, John Chief Operating Officer & General Counsel Collier Health Services, Inc., d/b/a Healthcare Network 2396583060	6/11/2024 7:25 AM
Details	340B ID	Update	New Registration		CH04170AC	6/11/2024 7:25 AM
Dates	Participating Approval Date	Update	New Registration		6/11/2024 7:25:42 AM	6/11/2024 7:25 AM
Details	State	Update	New Registration	Pending	Approved	6/11/2024 7:25 AM
Dates	Signed By Date	Update	New Registration		5/29/2024 12:24:14 PM	6/11/2024 7:25 AM
Dates	Start Date	Update	New Registration		7/1/2024 12:00:00 AM	6/11/2024 7:25 AM
Addresses	Main Address	Insert	New Registration		1454 Madison Ave W Immokalee, FL 34142-2200	5/29/2024 12:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1447099106	5/29/2024 12:24 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	5/29/2024 12:24 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1255170916	5/29/2024 12:24 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	5/29/2024 12:24 PM
Contacts	Authorizing Official	Insert	New Registration		Fletcher, John Chief Operating Officer & General Counsel Collier Health Services, Inc., d/b/a Healthcare Network 2396583060	5/29/2024 12:24 PM
Contacts	Primary Contact	Insert	New Registration		Woolley, Martine Vice President of Pharmacy Collier Health Services, Inc. 2396583030	5/29/2024 12:24 PM
Details	Assistance Received From Date	Insert	New Registration			5/29/2024 12:24 PM
Details	Assistance Received To Date	Insert	New Registration			5/29/2024 12:24 PM
Details	Last Recertification Date	Insert	New Registration			5/29/2024 12:24 PM
Details	Grant Number	Insert	New Registration		H80CS00735	5/29/2024 12:24 PM
Details	340B ID	Insert	New Registration			5/29/2024 12:24 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			5/29/2024 12:24 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			5/29/2024 12:24 PM
Details	Medicare Provider Number	Insert	New Registration			5/29/2024 12:24 PM
Details	Entity Name	Insert	New Registration		COLLIER HEALTH SERVICES INC	5/29/2024 12:24 PM
Details	NOFO Number	Insert	New Registration			5/29/2024 12:24 PM
Details	Program Code	Insert	New Registration		CH	5/29/2024 12:24 PM
Details	Entity Subname	Insert	New Registration		Healthcare Network - Mobile Outreach 1	5/29/2024 12:24 PM
Dates	Participating Approval Date	Insert	New Registration			5/29/2024 12:24 PM
Details	State	Insert	New Registration		Pending	5/29/2024 12:24 PM
Dates	Registration Date	Insert	New Registration		5/29/2024 12:24:11 PM	5/29/2024 12:24 PM
Dates	Signed By Date	Insert	New Registration			5/29/2024 12:24 PM
Dates	Start Date	Insert	New Registration			5/29/2024 12:24 PM
Terminations	Termination Comments	Insert	New Registration			5/29/2024 12:24 PM
Terminations	Termination Date	Insert	New Registration			5/29/2024 12:24 PM
Terminations	Termination Effective Date	Insert	New Registration			5/29/2024 12:24 PM
Terminations	Termination Reason	Insert	New Registration			5/29/2024 12:24 PM

340B Drug Pricing Program Database