Covered Entity Details

RRC100069-00 ADVENTHEALTH CARROLLWOOD (Approved) - information as of 5/29/2025 2:03:10 AM

Main Details

Name

ADVENTHEALTH CARROLLWOOD

Subdivision Name

Type

Rural Referral Center

Rural

340B ID

RRC100069-00

Medicare Provider Number

100069

Additional Details

Current Program Status

Approved

Registration Date

4/3/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/8/2025

Last Recertification Date

Contacts

Authorizing Official

AdventHealth Carrollwood
Christopher Tyson Sauder, CFO
(813) 558-4926

Primary Contact

AdventHealth Tampa
Rey Velez, 340B Program Coordinator
(813) 615-7244

Addresses

Street Address

7171 NORTH DALE MABRY HIGHWAY
TAMPA, FL 33614

Billing Address

AdventHealth Carrollwood
c/o AdventHealth
902 Inspiration Avenue
Suite 9100
Altamonte Springs, FL 32714

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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	010094300	1427068345

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	AHSSHC	RX PLUS PHARMACY	5050 WESLEY RD STE 110	APOPKA	FL	32712	04/08/2025	07/01/2025			04/08/2025
Contract Detail	AHSSHC	EXPEDIEN RX PHARMACY	5050 WESLEY RD STE 120	APOPKA	FL	32712	04/08/2025	07/01/2025			04/08/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
RRC100069-01	Child	RRC	ADVENTHEALTH CARROLLWOOD	AdventHealth Westchase ER - Emergency	10977 Sheldon Road	Tampa	FL	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Sauder, Christopher Tyson CFO AdventHealth Carrollwood 8135584926	4/8/2025 11:15 AM
Details	340B ID	Update	New Registration		RRC100069-00	4/8/2025 11:15 AM
Dates	Participating Approval Date	Update	New Registration		4/8/2025 11:15:15 AM	4/8/2025 11:15 AM
Details	State	Update	New Registration	Pending	Approved	4/8/2025 11:15 AM
Dates	Signed By Date	Update	New Registration		4/7/2025 3:46:23 PM	4/8/2025 11:15 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/8/2025 11:15 AM
Addresses	Main Address	Insert	New Registration		7171 NORTH DALE MABRY HIGHWAY TAMPA, FL 33614	4/3/2025 1:32 PM
Addresses	Billing Address	Insert	New Registration		AdventHealth Carrollwood c/o AdventHealth 902 Inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	4/3/2025 1:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2025 1:32 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010094300	4/3/2025 1:32 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/3/2025 1:32 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427068345	4/3/2025 1:32 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	4/3/2025 1:32 PM
Contacts	Primary Contact	Insert	New Registration		Velez, Rey 340B Program Coordinator AdventHealth Tampa 8136157244	4/3/2025 1:32 PM
Contacts	Authorizing Official	Insert	New Registration		Sauder, Christopher Tyson CFO AdventHealth Carrollwood 8135584926	4/3/2025 1:32 PM
Details	Assistance Received From Date	Insert	New Registration			4/3/2025 1:32 PM
Details	Assistance Received To Date	Insert	New Registration			4/3/2025 1:32 PM
Details	Last Recertification Date	Insert	New Registration			4/3/2025 1:32 PM
Details	Grant Number	Insert	New Registration			4/3/2025 1:32 PM
Details	340B ID	Insert	New Registration			4/3/2025 1:32 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/3/2025 1:32 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/3/2025 1:32 PM
Details	Medicare Provider Number	Insert	New Registration		100069	4/3/2025 1:32 PM
Details	Entity Name	Insert	New Registration		ADVENTHEALTH CARROLLWOOD	4/3/2025 1:32 PM
Details	NOFO Number	Insert	New Registration			4/3/2025 1:32 PM
Details	Program Code	Insert	New Registration		RRC	4/3/2025 1:32 PM
Details	Entity Subname	Insert	New Registration			4/3/2025 1:32 PM
Dates	Participating Approval Date	Insert	New Registration			4/3/2025 1:32 PM
Details	State	Insert	New Registration		Pending	4/3/2025 1:32 PM
Dates	Registration Date	Insert	New Registration		4/3/2025 1:32:46 PM	4/3/2025 1:32 PM
Dates	Signed By Date	Insert	New Registration			4/3/2025 1:32 PM
Dates	Start Date	Insert	New Registration			4/3/2025 1:32 PM
Terminations	Termination Comments	Insert	New Registration			4/3/2025 1:32 PM
Terminations	Termination Date	Insert	New Registration			4/3/2025 1:32 PM
Terminations	Termination Effective Date	Insert	New Registration			4/3/2025 1:32 PM
Terminations	Termination Reason	Insert	New Registration			4/3/2025 1:32 PM