Covered Entity Details

RRC100069-01 ADVENTHEALTH CARROLLWOOD (Approved) - information as of 5/13/2025 1:46:22 AM

Main Details

Name

ADVENTHEALTH CARROLLWOOD

Subdivision Name

AdventHealth Westchase ER - Emergency

Type

Rural Referral Center

Rural

340B ID

RRC100069-01

Medicare Provider Number

100069

Outpatient Facility Provider Number

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

10977 Sheldon Road
Tampa, FL 33626

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

Shipping Address 1

AdventHealth Carrollwood
7171 North Mabry Highway
Tampa, FL 33614

Shipping Address 2

AdventHealth Westchase ER
10977 Sheldon Road
Tampa, FL 33626

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
No records to display.

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		RRC100069-01	4/8/2025 11:15 AM
Details	Entity Subname	Update	New Registration	AdventHealth Westchase ER	AdventHealth Westchase ER - Emergency	4/8/2025 11:15 AM
Dates	Participating Approval Date	Update	New Registration		4/8/2025 11:15:35 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		4/3/2025 2:06:31 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		10977 Sheldon Road Tampa, FL 33626	4/3/2025 1:56 PM
Addresses	Billing Address	Insert	New Registration		AdventHealth Carrollwood c/o AdventHealth 902 Inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	4/3/2025 1:56 PM
Addresses	Shipping Address	Insert	New Registration		AdventHealth Carrollwood 7171 North Mabry Highway Tampa, FL 33614	4/3/2025 1:56 PM
Addresses	Shipping Address	Insert	New Registration		AdventHealth Westchase ER 10977 Sheldon Road Tampa, FL 33626	4/3/2025 1:56 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2025 1:56 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010094300	4/3/2025 1:56 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/3/2025 1:56 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1427068345	4/3/2025 1:56 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	4/3/2025 1:56 PM
Contacts	Primary Contact	Insert	New Registration		Velez, Rey 340B Program Coordinator AdventHealth Tampa 8136157244	4/3/2025 1:56 PM
Contacts	Authorizing Official	Insert	New Registration		Sauder, Christopher Tyson CFO AdventHealth Carrollwood 8135584926	4/3/2025 1:56 PM
Details	Assistance Received From Date	Insert	New Registration			4/3/2025 1:56 PM
Details	Assistance Received To Date	Insert	New Registration			4/3/2025 1:56 PM
Details	Last Recertification Date	Insert	New Registration			4/3/2025 1:56 PM
Details	Grant Number	Insert	New Registration			4/3/2025 1:56 PM
Details	340B ID	Insert	New Registration			4/3/2025 1:56 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/3/2025 1:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/3/2025 1:56 PM
Details	Medicare Provider Number	Insert	New Registration		100069	4/3/2025 1:56 PM
Details	Entity Name	Insert	New Registration		ADVENTHEALTH CARROLLWOOD	4/3/2025 1:56 PM
Details	NOFO Number	Insert	New Registration			4/3/2025 1:56 PM
Details	Program Code	Insert	New Registration		RRC	4/3/2025 1:56 PM
Details	Entity Subname	Insert	New Registration		AdventHealth Westchase ER	4/3/2025 1:56 PM
Dates	Participating Approval Date	Insert	New Registration			4/3/2025 1:56 PM
Details	State	Insert	New Registration		Pending	4/3/2025 1:56 PM
Dates	Registration Date	Insert	New Registration		4/3/2025 1:56:02 PM	4/3/2025 1:56 PM
Dates	Signed By Date	Insert	New Registration			4/3/2025 1:56 PM
Dates	Start Date	Insert	New Registration			4/3/2025 1:56 PM
Terminations	Termination Comments	Insert	New Registration			4/3/2025 1:56 PM
Terminations	Termination Date	Insert	New Registration			4/3/2025 1:56 PM
Terminations	Termination Effective Date	Insert	New Registration			4/3/2025 1:56 PM
Terminations	Termination Reason	Insert	New Registration			4/3/2025 1:56 PM