Covered Entity Details

DSH100025FE SACRED HEART HEALTH SYSTEM (Approved) - information as of 5/26/2025 12:57:09 AM

Main Details

Name

SACRED HEART HEALTH SYSTEM

Subdivision Name

SHMG Cardiology Destin-Bay - Cardiology

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH100025FE

Medicare Provider Number

100025

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/7/2025

Participating Start Date

7/1/2025

Participating Approval Date

5/21/2025

Last Recertification Date

Contacts

Authorizing Official

Sacred Heart Health System, Inc.
Susan Cornejo, Chief Operating Officer
(850) 416-6206

Primary Contact

Sacred Heart Health System, Inc.
Troy Russo, 340B Coordinator
(850) 416-2859

Addresses

Street Address

7720 US HWY 98
Suite 260
Miramar Beach, FL 32550

Billing Address
Same as Street Address

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
GA	000165217x	1922032424
LA	1735469	1922032424
MS	4605843	1922032424
TN	100025	1922032424
AL	HOS0025P	1922032424
FL	010076500	1922032424

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
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH100025AA	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - PREVATT	1549 AIRPORT BLVD.	PENSACOLA	FL	Active
DSH100025AB	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Primary Care Airport MOB	1549 AIRPORT BLVD.	PENSACOLA	FL	Active
DSH100025AC	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Primary Care Davis HWY	4501 N. DAVIS HIGHWAY	PENSACOLA	FL	Active
DSH100025AD	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - GUTIERREZ	5149 N. NINTH AVE	PENSACOLA	FL	Terminated
DSH100025AE	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - RAMOS	4313 OLD SPANISH TRAIL	PENSACOLA	FL	Active
DSH100025AF	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - NEUROSURGERY	5153 N. 9TH AVE.	PENSACOLA	FL	Terminated
DSH100025AG	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - TIGER POINT	1395 EL RITO DRIVE	GULF BREEZE	FL	Terminated
DSH100025AH	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP-PACE	3754 HIGHWAY 90,SUITE 200A	PACE	FL	Active
DSH100025AI	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP-PERDIDO	13139 SORRENTO ROAD	PENSACOLA	FL	Terminated
DSH100025AJ	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP- MILESTONE	400 MILESTONE BLVD.	CANTONMENT	FL	Terminated
DSH100025AK	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP- MOBILE HWY.	4929 MOBILE HWY.	PENSACOLA	FL	Terminated
DSH100025AN	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP- GULF SHORES	1700 WEST 2ND ST.	GULF SHORES	AL	Terminated
DSH100025AP	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP- FOLEY	1851 N. MCKENZIE STREET	FOLEY	AL	Terminated
DSH100025AQ	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP	1545 AIRPORT BLVD	PENSACOLA	FL	Terminated
DSH100025AR	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP	104 A Medical Park Drive	ANDALUSIA	AL	Active
DSH100025AS	Child	DSH	SACRED HEART HEALTH SYSTEM	Sacred Heart Pediatric Infusion	5153 N. 9th Avenue	Pensacola	FL	Active
DSH100025AT	Child	DSH	SACRED HEART HEALTH SYSTEM	Sacred Heart Adult Infusion Center	5153 N. 9th Ave.	Pensacola	FL	Active
DSH100025AU	Child	DSH	SACRED HEART HEALTH SYSTEM	Pediatric Surgery	5147 N. 9th Ave.	Pensacola	FL	Terminated
DSH100025AV	Child	DSH	SACRED HEART HEALTH SYSTEM	ENT - Dr. McWilliams	7720 Hwy. 98 W.	Miramar Beach	FL	Terminated
DSH100025AW	Child	DSH	SACRED HEART HEALTH SYSTEM	Sacred Heart Medical Group - Neurology	5153 N. 9th Ave.	Pensacola	FL	Active
DSH100025AX	Child	DSH	SACRED HEART HEALTH SYSTEM	Neurosurgery	5153 N. 9th Ave.	Pensacola	FL	Active
DSH100025AY	Child	DSH	SACRED HEART HEALTH SYSTEM	Bariatrics - Dr. Huyhn	4501 N. Davis Hwy.	Pensacola	FL	Terminated
DSH100025AZ	Child	DSH	SACRED HEART HOSPITAL	Tiger Point II / Family Medicine	1399 Country Club Road	Gulf Breeze	FL	Terminated
DSH100025BA	Child	DSH	SACRED HEART HEALTH SYSTEM	Multi-Providers - Mack Bayou	23 Mack Bayou Loop	Santa Rosa Beach	FL	Terminated
DSH100025BB	Child	DSH	SACRED HEART HEALTH SYSTEM	Dr. Jimenez Clinic	7720 Hwy. 98 W.	Miramar Beach	FL	Active
DSH100025BC	Child	DSH	SACRED HEART HEALTH SYSTEM	Dr. Yauch Clinic	120 Richard Jackson Blvd.	Panama City Beach	FL	Active
DSH100025BD	Child	DSH	SACRED HEART HEALTH SYSTEM	Dr. Zimmerman Clinic	7720 Hwy. 98 W.	Miramar Beach	FL	Terminated
DSH100025BE	Child	DSH	SACRED HEART HEALTH SYSTEM	MFMs	5153 N. 9th Ave.	Pensacola	FL	Active
DSH100025BF	Child	DSH	SACRED HEART HEALTH SYSTEM	OB/GYN - Dr. Hood	4586 Hwy. 20	Niceville	FL	Active
DSH100025BG	Child	DSH	SACRED HEART HEALTH SYSTEM	OB/GYN - Dr. Medlock	5153 N. 9th Ave.	Pensacola	FL	Terminated
DSH100025BH	Child	DSH	SACRED HEART HEALTH SYSTEM	OB/GYN - Pensacola	5153 N. 9th Ave.	Pensacola	FL	Active
DSH100025BI	Child	DSH	SACRED HEART HEALTH SYSTEM	OB/GYN - Destin	27 Mack Bayou Loop	Santa Rosa Beach	FL	Terminated
DSH100025BJ	Child	DSH	SACRED HEART HEALTH SYSTEM	Pediatrics - Destin	23 Mack Bayou Loop	Santa Rosa Beach	FL	Terminated
DSH100025BK	Child	DSH	SACRED HEART HEALTH SYSTEM	Internal Medicine - Dr. Martin	1549 Airport Blvd.	Pensacola	FL	Terminated
DSH100025BL	Child	DSH	SACRED HEART HEALTH SYSTEM	Primary Care - Dr. Clark	4586 E Hwy. 20	Niceville	FL	Active
DSH100025BM	Child	DSH	SACRED HEART HEALTH SYSTEM	Cardiology - Destin	7720 Hwy. 98 W.	Miramar Beach	FL	Active
DSH100025BN	Child	DSH	SACRED HEART HEALTH SYSTEM	Cardiology - Pensacola	5151 N. 9th Ave.	Pensacola	FL	Active
DSH100025BO	Child	DSH	SACRED HEART HEALTH SYSTEM	Destin Maternal Fetal Medicine/ OBGYN	7720 Hwy. 98 W.	Miramar Beach	FL	Active
DSH100025BP	Child	DSH	SACRED HEART HEALTH SYSTEM	Crestview Multi-Providers	550 W. Redstone Ave.	Crestview	FL	Active
DSH100025BQ	Child	DSH	SACRED HEART HEALTH SYSTEM	Destin Medical Park (PCP)	36500 Emerald Coast Pkwy.	Destin	FL	Active
DSH100025BR	Child	DSH	SACRED HEART HEALTH SYSTEM	Osteo Imaging	1549 Airport Blvd.	Pensacola	FL	Terminated
DSH100025BS	Child	DSH	SACRED HEART HEALTH SYSTEM	Pain Management - Dr. Chipman	7720 Hwy. 98 W.	Miramar Beach	FL	Terminated
DSH100025BT	Child	DSH	SACRED HEART HEALTH SYSTEM	Ortho Sports Medicine - Davis Hwy.	4521 N. Davis Hwy.	Pensacola	FL	Active
DSH100025BU	Child	DSH	SACRED HEART HEALTH SYSTEM	Orthopedics	4541 N. Davis Hwy.	Pensacola	FL	Active
DSH100025BV	Child	DSH	SACRED HEART HEALTH SYSTEM	Orthopedics Hand Center	4551 N. Davis Hwy.	Pensacola	FL	Active
DSH100025BW	Child	DSH	SACRED HEART HEALTH SYSTEM	Orthopedics Pre-Op	5147 N. 9th Ave.	Pensacola	FL	Terminated
DSH100025BX	Child	DSH	SACRED HEART HEALTH SYSTEM	Airport MRI	1549 Airport Blvd.	Pensacola	FL	Active
DSH100025BY	Child	DSH	SACRED HEART HEALTH SYSTEM	Airport CT	1549 Airport Blvd.	Pensacola	FL	Active
DSH100025BZ	Child	DSH	SACRED HEART HEALTH SYSTEM	Ann Baroco Center	5147 N. Ninth Ave. Suite G03	Pensacola	FL	Terminated
DSH100025CA	Child	DSH	SACRED HEART HOSPITAL	Airport Pain Management - Dr. H. Pauli	1549 Airport Blvd. Suite 410	Pensacola	FL	Terminated
DSH100025CB	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL Group / Cardiology Milton	5992 BERRYHILL ROAD	MILTON	FL	Terminated
DSH100025CC	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP -CRESTVIEW Meternal Fetal Med	550 W. Redstone Ave. Suite 450	Crestview	FL	Terminated
DSH100025CD	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP -AIRPORT Wound Care	1549 Airport Blvd, Suite 320	Pensacola	FL	Active
DSH100025CE	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP -DESTIN Neurology Outreach	7720 Hwy. 98 West, Suite 230	Miramar Beach	FL	Terminated
DSH100025CF	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP -RADIATION ONCOLOGY	1545 AIRPORT BLVD. SUITE 1000	Pensacola	FL	Active
DSH100025CG	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP -GYN SURG ONCOLOGY	1545 AIRPORT BLVD. SUITE 3200	Pensacola	FL	Terminated
DSH100025CH	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART HOSPITAL OF PENSACOLA / SACRED HEART MEDICAL GROUP- MOBILE HWY. Endocrinology Outreach	4929 MOBILE HWY	PENSACOLA	FL	Terminated
DSH100025CJ	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP -NICEVILLE Cardiology Outreach	4586 Hwy. 20 Suite C	Niceville	FL	Active
DSH100025CK	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART HOSPITAL OF PENSACOLA / SACRED HEART MEDICAL GROUP -DAVIS HWY. Endocrinology Outreach	4501 N DAVIS HWY	PENSACOLA	FL	Terminated
DSH100025CL	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART HOSPITAL OF PENSACOLA / SACRED HEART MEDICAL GROUP -MILESTONE Cardiology Outreach	400 MILESTONE BLVD	CANTONMENT	FL	Terminated
DSH100025CM	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP-PACE OBGYN	3754 HIGHWAY 90,SUITE 220	PACE	FL	Active
DSH100025CN	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL CROUP / SACRED HEART MEDICAL GROUP -Cardiology PACE Outreach	3754 HIGHWAY 90	PACE	FL	Active
DSH100025CP	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP -Cardiology Defuniak Outreach	21 W Main Ave	DEFUNIAK SPRINGS	FL	Terminated
DSH100025CQ	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP -THORACIC SURG ONCOLOGY	1545 AIRPORT BLVD	PENSACOLA	FL	Terminated
DSH100025CR	Child	DSH	SACRED HEART HEALTH SYSTEM	Sacred Heart Outpatient Transplant Clinic - Renal Transplants	5149 N. 9th Avenue	Pensacola	FL	Active
DSH100025CS	Child	DSH	SACRED HEART HEALTH SYSTEM	FSED Navarre - Emergency	7334 Navarre PKWY.	Navarre	FL	Active
DSH100025CT	Child	DSH	SACRED HEART HEALTH SYSTEM	FSED Nine Mile Road - Emergency	1501 W. NINE MILE ROAD	PENSACOLA	FL	Active
DSH100025CU	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Sports and Shoulder Center - Orthopedics	400 Milestone Blvd	Cantonment	FL	Active
DSH100025CV	Child	DSH	SACRED HEART HEALTH SYSTEM	Oncology - Lynn Haven - Oncology	615 N. Bonita Avenue, Suite 3-A	Panama City	FL	Active
DSH100025CW	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG PC Downtown (Wahoo Stadium) - Primary Care	151 West Main Street	Pensacola	FL	Active
DSH100025CX	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Peds Neurology POB - Neurology	5153 N 9th Ave	Pensacola	FL	Active
DSH100025CY	Child	DSH	SACRED HEART HEALTH SYSTEM	SH Residency OBGYN Trinity - OBGYN	1657 Trinity Drive	Pensacola	FL	Active
DSH100025CZ	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Cardiology Depaul 318 - Cardiology	5147 N 9th Ave, Suite 318	Pensacola	FL	Active
DSH100025E	Child	DSH	SACRED HEART HEALTH SYSTEM	MEDICAL GROUP	4451 BAYOU BLVD.	PENSACOLA	FL	Terminated
DSH100025EA	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Rheum Pensacola - Rheumatology	5190 Bayou Blvd, Building #2	Pensacola	FL	Active
DSH100025EB	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG PC Gulf Breeze - Primary Care	2569 Gulf Breeze Pkwy	Gulf Breeze	FL	Active
DSH100025EC	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Peds Endocrinology POB - Endocrinology	5153 N 9TH AVE	Pensacola	FL	Active
DSH100025ED	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG PC 5 Points - Primary Care	5607 Woodbine Rd	Pace	FL	Active
DSH100025EE	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Endocrinology Destin - Endocrinology	7720 US Hwy 98 West	Miramar Beach	FL	Active
DSH100025EF	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG PC Destin Market Shops (DMKT) - Primary Care	9375 Emerald Coast Pkwy	Miramar Beach	FL	Active
DSH100025EG	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Rheum at Destin Market Shops (DMKT) - Rheumatology	9375 Emerald Coast Pkwy	Miramar Beach	FL	Active
DSH100025EH	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG PC Milestone MOB - Primary Care	2156 West Nine Mile Road	Pensacola	FL	Active
DSH100025EJ	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Cardiology Milestone MOB - Cardiology	2156 West Nine Mile Road	Pensacola	FL	Active
DSH100025EK	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG PC Pace MOB 300 - Primary Care	3754 Highway 90	Pace	FL	Active
DSH100025EL	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG PC Freeport - Primary Care	281 STATE HWY 20 EAST	Freeport	FL	Active
DSH100025EM	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG GYN OB Milestone MOB - Gynecology and Obstetrics	2156 West Nine Mile Road	Pensacola	FL	Active
DSH100025EN	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Peds Oncology POB - Oncology	5153 N 9th Ave	Pensacola	FL	Active
DSH100025EP	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Peds Pulmonology POB - Pulmonology	5153 N 9th Ave	Pensacola	FL	Active
DSH100025EQ	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Peds Gastro POB - Gastroenterology	5153 N 9th Ave	Pensacola	FL	Active
DSH100025ER	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Bay Neurology - Neurology	801 E 6th Street	Panama City	FL	Active
DSH100025ES	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Urology Davis Hwy - Urology	4511 N Davis Hwy	Pensacola	FL	Active
DSH100025ET	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG BAY PC Ocean Park - Primary Care	23040 Panama City Beach Parkway	Panama City Beach	FL	Active
DSH100025EU	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG PC Watersound Inlet Beach - Primary Care	180 N Watersound Pkwy	Inlet Beach	FL	Active
DSH100025EV	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG BAY PC Northside - Primary Care	2101 Northside Dr	Panama City	FL	Active
DSH100025EW	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Ortho Hand Summit MOB - Orthopedics	1890 Summit Blvd	Pensacola	FL	Active
DSH100025EX	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG OBGYN Destin 210 - OBGYN	7720 US Hwy 98 West	Miramar Beach	FL	Active
DSH100025EY	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART HOSPITAL OF PENSACOLA - SHMG Primary Care -Martin STEC	4501 NORTH DAVIS HWY	PENSACOLA	FL	Active
DSH100025EZ	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Peds Nephrology POB - Nephrology	5153 N 9th Ave	Pensacola	FL	Active
DSH100025FA	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Rheumatology Outreach Miramar - Rheumatology	7720 US Hwy 98 West	Miramar Beach	FL	Active
DSH100025FB	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG BAY Lynn Haven PC - Primary care	725 Ohio Ave	Lynn Haven	FL	Active
DSH100025FC	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Summit Bariatrics (weight loss) - Bariatrics	1890 Summit Blvd, STE 120	Pensacola	FL	Active
DSH100025FD	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Pharmacy Services AMP 200E - Primary Care Pharmacotherapy	1549 Airport Blvd	Pensacola	FL	Approved
DSH100025FE	Child	DSH	SACRED HEART HEALTH SYSTEM	SHMG Cardiology Destin-Bay - Cardiology	7720 US HWY 98	Miramar Beach	FL	Approved
DSH100025L	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP AT DAVIS HIGHWAY	8331 NORTH DAVIS HIGHWAY	PENSACOLA	FL	Terminated
DSH100025M	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP AT MILTON	5992 Berryhill Road	MILTON	FL	Terminated
DSH100025P	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP AT DESTIN	27 Mack Bayou Loop	Santa Rosa Beach	FL	Active
DSH100025R	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP-DR. MAMISH	1549 AIRPORT BLVD	PENSACOLA	FL	Active
DSH100025T	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP	1549 AIRPORT BLVD.	PENSACOLA	FL	Active
DSH100025U	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL ONCOLOGY GROUP	1545 AIRPORT BLVD.	PENSACOLA	FL	Active
DSH100025V	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - PUGH	1549 AIRPORT BLVD.	PENSACOLA	FL	Active
DSH100025W	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - DANIELS	1549 AIRPORT BLVD.	PENSACOLA	FL	Active
DSH100025Y	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - GORTON	1549 AIRPORT BLVD.	PENSACOLA	FL	Active
DSH100025Z	Child	DSH	SACRED HEART HEALTH SYSTEM	SACRED HEART MEDICAL GROUP - ASSOCIATE HEALTHCARE CLINIC	1549 AIRPORT BLVD.	PENSACOLA	FL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Cornejo, Susan Chief Operating Officer Sacred Heart Health System, Inc. 8504166206	5/21/2025 12:42 PM
Details	340B ID	Update	New Registration		DSH100025FE	5/21/2025 12:42 PM
Details	Entity Subname	Update	New Registration	SHMG Cardiology Destin-Bay	SHMG Cardiology Destin-Bay - Cardiology	5/21/2025 12:42 PM
Dates	Participating Approval Date	Update	New Registration		5/21/2025 12:42:11 PM	5/21/2025 12:42 PM
Details	State	Update	New Registration	Pending	Approved	5/21/2025 12:42 PM
Dates	Signed By Date	Update	New Registration		4/11/2025 12:35:45 PM	5/21/2025 12:42 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	5/21/2025 12:42 PM
Addresses	Main Address	Insert	New Registration		7720 US HWY 98 Suite 260 Miramar Beach, FL 32550	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000165217x	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1735469	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		4605843	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		MS	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100025	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TN	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		HOS0025P	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		AL	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010076500	4/7/2025 7:57 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/7/2025 7:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1922032424	4/7/2025 7:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		GA	4/7/2025 7:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1922032424	4/7/2025 7:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	4/7/2025 7:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1922032424	4/7/2025 7:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		MS	4/7/2025 7:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1922032424	4/7/2025 7:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		TN	4/7/2025 7:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1922032424	4/7/2025 7:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		AL	4/7/2025 7:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1922032424	4/7/2025 7:57 PM
Medicaid Billing	NPI: State	Insert	New Registration		FL	4/7/2025 7:57 PM
Contacts	Primary Contact	Insert	New Registration		Russo, Troy 340B Coordinator Sacred Heart Health System, Inc. 8504162859	4/7/2025 7:57 PM
Contacts	Authorizing Official	Insert	New Registration		Cornejo, Susan Chief Operating Officer Sacred Heart Health System, Inc. 8504166206	4/7/2025 7:57 PM
Details	Assistance Received From Date	Insert	New Registration			4/7/2025 7:57 PM
Details	Assistance Received To Date	Insert	New Registration			4/7/2025 7:57 PM
Details	Last Recertification Date	Insert	New Registration			4/7/2025 7:57 PM
Details	Grant Number	Insert	New Registration			4/7/2025 7:57 PM
Details	340B ID	Insert	New Registration			4/7/2025 7:57 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/7/2025 7:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/7/2025 7:57 PM
Details	Medicare Provider Number	Insert	New Registration		100025	4/7/2025 7:57 PM
Details	Entity Name	Insert	New Registration		SACRED HEART HEALTH SYSTEM	4/7/2025 7:57 PM
Details	NOFO Number	Insert	New Registration			4/7/2025 7:57 PM
Details	Program Code	Insert	New Registration		DSH	4/7/2025 7:57 PM
Details	Entity Subname	Insert	New Registration		SHMG Cardiology Destin-Bay	4/7/2025 7:57 PM
Dates	Participating Approval Date	Insert	New Registration			4/7/2025 7:57 PM
Details	State	Insert	New Registration		Pending	4/7/2025 7:57 PM
Dates	Registration Date	Insert	New Registration		4/7/2025 7:57:02 PM	4/7/2025 7:57 PM
Dates	Signed By Date	Insert	New Registration			4/7/2025 7:57 PM
Dates	Start Date	Insert	New Registration			4/7/2025 7:57 PM
Terminations	Termination Comments	Insert	New Registration			4/7/2025 7:57 PM
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