Covered Entity Details

DSH100135 TALLAHASSEE MEMORIAL HEALTHCARE, INC (Active) - information as of 4/25/2025 8:34:05 PM

Main Details

Name

TALLAHASSEE MEMORIAL HEALTHCARE, INC

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH100135

Medicare Provider Number

100135

Additional Details

Current Program Status

Active

Registration Date

9/14/2007

Participating Start Date

1/1/2005

Participating Approval Date

9/14/2007

Last Recertification Date

9/6/2024

Contacts

Authorizing Official

Tallahassee Memorial HealthCare
Priscilla Needham, Chief Financial Officer
(850) 431-0630

Primary Contact

Tallahassee Memorial HealthCare
Louis Kynard, Director of Pharmacy
(850) 431-5030

Addresses

Street Address

1300 MICCOSUKEE ROAD
TALLAHASSEE, FL 32308

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
1/18/12 change PC from Coumbe to Brown JH	01/18/2012

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	010113300	1437177664
GA	000100009A	1437177664

Shipping Addresses

Shipping Address 1

TMH Specialty Pharmacy
1401 Miccosukee Rd
100-B
Tallahassee, FL 32308

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/11/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/11/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/11/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/11/2022	07/01/2022	10/01/2023	04/24/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/11/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/11/2022	07/01/2022		07/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/11/2022	07/01/2022		07/01/2022
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/16/2024	04/01/2024		04/01/2024
Contract Detail	BIOPLUS SPECIALTY INFUSION AL LLC	2511 ROSS CLARK CIR		DOTHAN	AL	36301	04/12/2022	07/01/2022	04/01/2024	04/15/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	04/12/2022	07/01/2022	04/01/2024	04/15/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	04/12/2022	07/01/2022	04/01/2024	04/15/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	3439 NORTH 12TH AVENUE SUITE A AND B	PENSACOLA	FL	32503-4008	07/14/2023	10/01/2023	01/17/2025	02/06/2025
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	2345 WATERS DRIVE	MENDOTA HEIGHTS	MN	55120	01/21/2025	04/01/2025		04/01/2025
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	6 SPRING MILL DR	MALVERN	PA	19355	01/21/2025	04/01/2025		04/01/2025
Contract Detail	CORAM HEALTHCARE CORPORATION OF FLORIDA	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	8508 BENJAMIN RD SUITE C	TAMPA	FL	33634-1241	07/14/2023	10/01/2023	01/17/2025	02/06/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/14/2022	07/01/2022		07/01/2022
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	04/11/2022	07/01/2022		07/01/2022
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/11/2022	07/01/2022		07/01/2022
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/11/2022	07/01/2022		07/01/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/11/2022	07/01/2022		07/01/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/11/2022	07/01/2022		07/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04535	817 EAST SHOTWELL ST	BAINBRIDGE	GA	39819	04/14/2022	07/01/2022		07/01/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04515	14857 US HWY 19 S.	THOMASVILLE	GA	31792	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04024	5466 THOMASVILLE RD N	TALLAHASSEE	FL	32312	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA CVS/PHARMACY #10482	822 WEST PENSACOLA STREET	TALLAHASSEE	FL	32304-8036	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 07958	3644 COOLIDGE COURT	TALLAHASSEE	FL	32311	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01256	1300 APALACHEE PKWY	TALLAHASSEE	FL	32301	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04099	1390 S. JEFFERSON ST.	MONTICELLO	FL	32344	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04062	407 E. BASE ST.	MADISON	FL	32340	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05167	12 DECATUR ST	CHATTAHOOCHEE	FL	32324	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 00633	3090 S MONROE ST	TALLAHASSEE	FL	32301	04/14/2022	07/01/2022	07/01/2023	07/17/2023
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 07895	3035 APALACHEE PKWY.	TALLAHASSEE	FL	32301	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03910	3479 THOMASVILLE RD	TALLAHASSEE	FL	32309	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05165	139 AVENUE E	APALACHICOLA	FL	32320	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05246	110 HIGHWAY 98	PORT SAINT JOE	FL	32456	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04478	3831 N MONROE ST	TALLAHASSEE	FL	32303	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04472	105 WEST HAMPTON SPRINGS AVE	PERRY	FL	32347	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05069	2668 CRAWFORDVILLE HWY	CRAWFORDVILLE	FL	32327	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03624	1208 W. JEFFERSON ST.	QUINCY	FL	32351	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 00710	1708 N MONROE ST	TALLAHASSEE	FL	32303	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 17089	3700 BRADFORDVILLE RD	TALLAHASSEE	FL	32309	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05025	1875 CAPITAL CIR NE	TALLAHASSEE	FL	32308	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04480	1037 MAIN STREET	CHIPLEY	FL	32428	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04639	5670 N MONROE ST	TALLAHASSEE	FL	32303	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04469	1819 W TENNESSEE ST	TALLAHASSEE	FL	32304	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03245	4684 HIGHWAY 90	MARIANNA	FL	32446	04/14/2022	07/01/2022		07/01/2022
Contract Detail	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 16288	2120 APALACHEE PKWY	TALLAHASSEE	FL	32301	04/14/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM INFUSION SERVICES 201, INC.	5700 DOT COM CT STE 1030		OVIEDO	FL	32765-3400	04/19/2022	07/01/2022	10/14/2024	01/21/2025
Contract Detail	OPTUM INFUSION SERVICES 202, INC.	9655 FLORIDA MINING BLVD W	STE 411	JACKSONVILLE	FL	32257-2041	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM INFUSION SERVICES 204, INC.	826 CREIGHTON RD, UNIT A-103		PENSACOLA	FL	32504	04/19/2022	07/01/2022	08/05/2022	10/28/2022
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM INFUSION SERVICES 553, LLC	6531 MERIDIEN DR	SUITE 113	RALEIGH	NC	27616	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	01/21/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/19/2022	07/01/2022		07/01/2022
Contract Detail	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	04/19/2022	07/01/2022	07/01/2022	10/28/2022
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/19/2022	07/01/2022	07/01/2022	07/15/2022
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	10/28/2022	01/01/2023		01/01/2023
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	04/11/2022	07/01/2022	07/01/2022	07/15/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY# 11235	9555 KINGS CHARTER DR., SUITE D	ASHLAND	VA	23005	04/14/2022	07/01/2022	07/01/2023	07/17/2023
Contract Detail	PROCARE PHARMACY, L.L.C.	CVS/PHARMACY #48637	2700 NORTHEAST EXPY NE STE B800 BUILDING B	ATLANTA	GA	30345	07/14/2023	10/01/2023		10/01/2023
Contract Detail	PROXSYSRX FL LLC	PHARMACY AT TMH	1401 MICCOSUKEE RD SUITE 100	TALLAHASSEE	FL	32308	07/14/2023	10/01/2023		10/01/2023
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0610	5032 CAPITAL CIRCLE SW, SUITE 1	TALLAHASSEE	FL	32305	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0887	3551 BLAIRSTONE RD	TALLAHASSEE	FL	32301	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS INC	PUBLIX PHARMACY #0857	6615 MAHAN DRIVE	TALLAHASSEE	FL	32308	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS INC	PUBLIX PHARMACY #0782	800 OCALA ROAD	TALLAHASSEE	FL	32304	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS INC	PUBLIX PHARMACY #0852	1700 N MONROE STREET	TALLAHASSEE	FL	32303	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS, INC	PUBLIX PHARMACY #1051	101 NORTH BLAIRSTONE ROAD	TALLAHASSEE	FL	32301	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1656	5678 CAPITAL CIRCLE NW	TALLAHASSEE	FL	32303	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #3213	1950 SAND LAKE RD, BLDG #5	ORLANDO	FL	32809	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX CENTRAL PHARMACY #3201	2424 ORLANDO CENTRAL PARKWAY	ORLANDO	FL	32809	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1401	3122 MAHAN DR.	TALLAHASSEE	FL	32308	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1427	2111 NE CAPITAL CIRCLE	TALLAHASSEE	FL	32308	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1540	378 VETERAN'S PARKWAY NORTH	MOULTRIE	GA	31768	04/14/2022	07/01/2022	04/01/2024	04/15/2024
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1306	3521 THOMASVILLE RD	TALLAHASSEE	FL	32309	04/14/2022	07/01/2022		07/01/2022
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1498	13775 HIGHWAY 19 S	THOMASVILLE	GA	31792	04/14/2022	07/01/2022	04/01/2024	04/15/2024
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1798	2343 CRAWFORDVILLE HIGHWAY	CRAWFORDVILLE	FL	32327	04/15/2024	07/01/2024		07/01/2024
Contract Detail	PUBLIX SUPERMARKETS	PUBLIX PHARMACY #0533	6753 THOMASVILLE RD.	TALLAHASSEE	FL	32312	04/14/2022	07/01/2022		07/01/2022
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	07/13/2023	10/01/2023		10/01/2023
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	07/13/2023	10/01/2023		10/01/2023
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY # 10-4520	4021LAGNIAPPE WAY		TALLAHASSEE	FL	32317	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY 10-0488	1940 PAT THOMAS PARKWAY		QUINCY	FL	32351	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY 10-1077	3535 APALACHEE PARKWAY		TALLAHASSEE	FL	32311	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY 10-1223	5500 THOMASVILLE RD		TALLAHASSEE	FL	32312	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY 10-1408	4400 W. TENNESSEE		TALLAHASSEE	FL	32304	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY 10-3307	35 MIKE STEWART DRIVE		CRAWFORDVILLE	FL	32327	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY 10-4427	3221 N. MONROE STREET		TALLSHASSEE	FL	32303	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY 10-5172	1900 SOUTH JEFFERSON ST		PERRY	FL	32348	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/14/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO	DBA: WALGREENS #10831	1410 E SHOTWELL ST	BAINBRIDGE	GA	39819	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO	DBA: WALGREENS #11794	11343 US HIGHWAY 319 N	THOMASVILLE	GA	31757	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10901	2913 MAHAN DR	TALLAHASSEE	FL	32308	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07583	3820 N MONROE ST	TALLAHASSEE	FL	32303-2136	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21200	1120 E UNIVERSITY AVE STE 200	GAINESVILLE	FL	32641	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09578	2580 CRAWFORDVILLE HWY	CRAWFORDVILLE	FL	32327-2174	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12578	2117 S BYRON BUTLER PKWY	PERRY	FL	32348	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02074	1202 N MAGNOLIA DR	TALLAHASSEE	FL	32308-4634	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 11537	414 S. MAGNOLIA DRIVE	TALLAHASSEE	FL	32301	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #19880	301 S BROAD ST	THOMASVILLE	GA	31792	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03430	2349 N MONROE ST	TALLAHASSEE	FL	32303	04/11/2022	07/01/2022	02/25/2025	02/25/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04311	3531 THOMASVILLE ROAD	TALLAHASSEE	FL	32309	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01902	6680 THOMASVILLE RD	TALLAHASSEE	FL	32312-3836	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10147	1217 W JEFFERSON ST	QUINCY	FL	32351-2125	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10717	140 CAPITAL CIRCLE SW	TALLAHASSEE	FL	32304	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04091	2009 W. TENNESSEE STREET	TALLAHASSEE	FL	32304	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16527	1801 N MAIN ST	JACKSONVILLE	FL	32206	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21162	1301 PALM AVE STE 210	JACKSONVILLE	FL	32207	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS SPECIALTY PHARMACY #12146	1200 KUHL AVE	ORLANDO	FL	32806	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #13072	8333 N DAVIS HWY STE 50	PENSACOLA	FL	32514	07/15/2022	10/01/2022		10/01/2022
Contract Detail	Walgreens #21395	Walgreens Central Fill #21395	5710 Young Pine Rd	Orlando	FL	32829	10/28/2022	01/01/2023		01/01/2023
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	04/11/2022	07/01/2022		07/01/2022
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/17/2023	10/01/2023		10/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/16/2024	04/01/2024		04/01/2024
Contract Detail	ZENITH CARE INC DBA WELLPACK PHARMACY	1624 CAPITAL CIR NE STE 210		TALLAHASSEE	FL	32308-7410	04/14/2022	07/01/2022	07/31/2023	01/16/2024

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH100135A	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Emergency Center - Northeast	1260 Metropolitan Boulevard	Tallahassee	FL	Active
DSH100135AA	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Cardiology HFC	1609 PHYSICIANS DR	TALLAHASSEE	FL	Active
DSH100135AB	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Urology Specialists	2619 Centennial Blvd	TALLAHASSEE	FL	Active
DSH100135AC	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Healthcare Cardiology SMG - TMHPP Cardiology	1300 Medical Drive	Tallahassee	FL	Active
DSH100135AD	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Family Medicine Residency - Primary Care	1301 HODGES DR	TALLAHASSEE	FL	Active
DSH100135AE	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMH Physician Partners - Heart Rhythm Clinic - Electrophysiology	2100 Centerville Road	Tallahassee	FL	Active
DSH100135AF	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMH Physician Partners - Primary Care in Carrabelle - TMHPP Franklin - Carrabelle	110Th NE 5th ST	Carabelle	FL	Terminated
DSH100135AG	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Metabolic Health Center - Bariatric Medical Center - Bariatric Medical Center	2633 Centennial Blvd	Tallahassee	FL	Active
DSH100135AH	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMH Physician Partners - Primary Care in Apalachicola - TMHPP Franklin - Apalachicola	137 12TH St	Apalachicola	FL	Terminated
DSH100135AJ	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Metabolic Health Center - Outpatient Diabetes Center - Outpatient Diabetes Center	2633 Centennial Blvd	Tallahassee	FL	Active
DSH100135AK	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Metabolic Health Center- Endocrinology - Physician Partners Endocrinology Specialists	2633 Centennial Blvd	Tallahassee	FL	Active
DSH100135AL	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Urgent Care Center in Southwood - Tallahassee Memorial Urgent Care Center- Southwood	3900 Esplanade Way	Tallahassee	FL	Active
DSH100135AM	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Metabolic Health Center- Lipids Center - Lipid Center	2633 Centennial Blvd	Tallahassee	FL	Active
DSH100135AN	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMH Physician Partners - Oral Maxillofacial Trauma Surgery - TMHPP Oral Maxillofacial Trauma Surgery	1401 Centerville Rd	Tallahassee	FL	Active
DSH100135AP	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMH PHYSICIAN PARTNERS PANAMA CITY - TMH Physician Partners - Primary Care in Panama City Beach	1002 N. Arnold Rd (Highway 79)	Panama City Beach	FL	Active
DSH100135AQ	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMH PHYSICIAN PARTNERS CARDIAC & INTERNAL MEDICINE SPECIALISTS-NORTHEAST - Physician Partners CIM-NE	1260 Metropolitan Blvd	Tallahassee	FL	Active
DSH100135AR	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMH PHYSICIAN PARTNERS RHEUMATOLOGY - TMH Physician Partners – Rheumatology	3900 Esplanade Way	Tallahassee	FL	Active
DSH100135B	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Physician Partners Southwood-Medical Specialists	3900 Esplanade Way	Tallahassee	FL	Active
DSH100135C	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Physician Partners Perry	555 N. Byron Butler Parkway	Perry	FL	Active
DSH100135D	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Transition Care Center	3333 Capital Oaks Drive	Tallahassee	FL	Active
DSH100135E	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMHPP Chronic Pain Management	1633 Physicians Drive	Tallahassee	FL	Active
DSH100135F	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Physician Partners Wakulla	15 Council Moore Road	Crawfordville	FL	Active
DSH100135G	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Physician Partners Quincy	178 Lasalle Leffall Drive	Quincy	FL	Active
DSH100135H	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Physician Partners Monticello	1549 S. Jefferson Street	Monticello	FL	Active
DSH100135J	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Physician Partners Blountstown	17808 NE Charlie Johns Street	Blountstown	FL	Active
DSH100135K	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Cancer Center	1775 ONE HEALING PLACE	TALLAHASSEE	FL	Active
DSH100135L	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	Tallahassee Memorial Wound Healing Center - Wound Healing Center	1505 Surgeons Drive	Tallahassee	FL	Terminated
DSH100135M	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Radiation Oncology	1775 ONE HEALING PL	TALLAHASSEE	FL	Active
DSH100135N	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - TMHPP Surgical Specialists with Services by Surgical Associates of Tallahassee	1405 CENTERVILLE RD	TALLAHASSEE	FL	Active
DSH100135P	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Surgical Specialist	1401 CENTERVILLE RD	TALLAHASSEE	FL	Active
DSH100135Q	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE - Primary Care	2888 MAHAN DR	TALLAHASSEE	FL	Terminated
DSH100135R	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Cancer Center Physicians	1775 ONE HEALING PL	TALLAHASSEE	FL	Active
DSH100135S	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Neurology Specialists	2473 Care Drive	TALLAHASSEE	FL	Active
DSH100135T	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMH Urgent Care Center - Urgent Care Center	1541 Medical Drive	Tallahassee	FL	Active
DSH100135U	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Internal Medicine SMG	1300 MEDICAL DR	TALLAHASSEE	FL	Active
DSH100135V	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMHPP SMG Cardiothoracic Surgery - Cardiothoracic Surgery	1405 Centerville Road	Tallahassee	FL	Active
DSH100135W	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMHPP Surgical Specialist - TMPP Surgical Specialists	1401 Centerville Road	Tallahassee	FL	Active
DSH100135X	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TMHPP Pulmonary, Critical Care, & Sleep Specialists - Intensivists Services	1607 Saint James Court	Tallahassee	FL	Active
DSH100135Y	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Primary Care	6721 THOMASVILLE RD	TALLAHASSEE	FL	Active
DSH100135Z	Child	DSH	TALLAHASSEE MEMORIAL HEALTHCARE, INC	TALLAHASSEE MEMORIAL HEALTHCARE INC - Cardiology/Internal Medicine - Nuclear Medicine	1300 MEDICAL DR	TALLAHASSEE	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/8/2023 11:17:33 AM	9/6/2024 2:41:44 PM	9/6/2024 2:41 PM
Addresses	Shipping Address	Insert	Change Request		TMH Specialty Pharmacy 1401 Miccosukee Rd 100-B Tallahassee, FL 32308	3/8/2024 6:21 AM
Details	Last Recertification Date	Update	Recertification	9/19/2022 8:14:58 AM	9/8/2023 11:17:33 AM	9/8/2023 11:17 AM
Contacts	Authorizing Official	Update	Change Request	GIUDICE, WILLIAM A. CHIEF FINANCIAL OFFICER Tallahassee Memorial HealthCare Inc 8504315238	Needham, Priscilla Chief Financial Officer Tallahassee Memorial HealthCare 8504310630	2/25/2023 8:18 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 5:22:21 PM	9/19/2022 8:14:58 AM	9/19/2022 8:14 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	101133 (FL)		10/29/2021 3:44 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	101133 (GA)		10/29/2021 3:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/29/2021 3:44 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010113300	10/29/2021 3:44 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	10/29/2021 3:44 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/29/2021 3:44 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		000100009A	10/29/2021 3:44 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	10/29/2021 3:44 PM
Contacts	Primary Contact	Update	Change Request	Brown, Bernadette Director of Pharmacy Tallahassee Memorial Healthcare, Inc 8504315030	Kynard, Louis Director of Pharmacy Tallahassee Memorial HealthCare 8504315030	9/23/2021 6:54 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 11:19:11 AM	8/27/2021 5:22:21 PM	8/27/2021 5:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/2/2020 11:19 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		101133	9/2/2020 11:19 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/2/2020 11:19 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437177664	9/2/2020 11:19 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/2/2020 11:19 AM
Medicaid Billing	NPI: State	Update	Recertification		GA	9/2/2020 11:19 AM
Details	Last Recertification Date	Update	Recertification	9/8/2019 8:11:28 PM	9/2/2020 11:19:11 AM	9/2/2020 11:19 AM
Details	Last Recertification Date	Update	Recertification	8/29/2018 1:14:29 PM	9/8/2019 8:11:28 PM	9/8/2019 8:11 PM
Details	Last Recertification Date	Update	Recertification	11/17/2017 9:33:45 AM	8/29/2018 1:14:29 PM	8/29/2018 1:14 PM
Details	Last Recertification Date	Update	Recertification	9/6/2016 12:00:00 AM	11/17/2017 9:33:45 AM	11/17/2017 9:33 AM
Contacts	Primary Contact	Update		Brown, Bernadette Director of Pharmacy 8504315030	Brown, Bernadette Director of Pharmacy Tallahassee Memorial Healthcare, Inc 8504315030	11/9/2017 9:03 AM
Contacts	Authorizing Official	Update		GIUDICE, WILLIAM A. CHIEF FINANCIAL OFFICER 8504315238	GIUDICE, WILLIAM A. CHIEF FINANCIAL OFFICER Tallahassee Memorial HealthCare Inc 8504315238	10/30/2017 8:59 AM
Addresses	Main Address	Insert			1300 MICCOSUKEE ROAD TALLAHASSEE, FL 32308	9/6/2016 3:50 PM
Contacts	Primary Contact	Insert			Brown, Bernadette Director of Pharmacy 8504315030	9/6/2016 3:50 PM
Contacts	Authorizing Official	Insert			GIUDICE, WILLIAM A. CHIEF FINANCIAL OFFICER 8504315238	9/6/2016 3:50 PM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	9/6/2016 12:00:00 AM	9/6/2016 3:50 PM
Details	Last Recertification Date	Update		8/13/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 11:18 AM
Details	Last Recertification Date	Update		8/30/2013 12:00:00 AM	8/13/2014 12:00:00 AM	8/13/2014 2:13 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/30/2013 12:00:00 AM	8/30/2013 12:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	5/15/2012 7:22 AM
Medicaid Billing	Medicaid: Number	Insert			101133	5/15/2012 7:22 AM
Medicaid Billing	Medicaid: State	Insert			FL	5/15/2012 7:22 AM
Medicaid Billing	NPI: Number	Insert			1437177664	5/15/2012 7:22 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/15/2012 7:22 AM
Details	Comments Public	Insert			1/18/12 change PC from Coumbe to Brown JH	1/18/2012 12:57 PM
Dates	Participating Approval Date	Update		9/14/2007 5:57:37 PM	9/14/2007 12:00:00 AM	1/18/2012 12:47 PM
Details	Last Recertification Date	Insert				9/14/2007 5:57 PM
Details	Grant Number	Insert				9/14/2007 5:57 PM
Details	340B ID	Insert			DSH100135	9/14/2007 5:57 PM
Details	Is Authorizing Official EHB Data	Insert				9/14/2007 5:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/14/2007 5:57 PM
Details	Medicare Provider Number	Insert			100135	9/14/2007 5:57 PM
Details	Entity Name	Insert			TALLAHASSEE MEMORIAL HEALTHCARE, INC	9/14/2007 5:57 PM
Details	Program Code	Insert			DSH	9/14/2007 5:57 PM
Details	Entity Subname	Insert				9/14/2007 5:57 PM
Dates	Participating Approval Date	Insert			9/14/2007 5:57:37 PM	9/14/2007 5:57 PM
Details	State	Insert			Active	9/14/2007 5:57 PM
Dates	Registration Date	Insert			9/14/2007 12:00:00 AM	9/14/2007 5:57 PM
Dates	Signed By Date	Insert				9/14/2007 5:57 PM
Dates	Start Date	Insert			1/1/2005 12:00:00 AM	9/14/2007 5:57 PM
Terminations	Termination Comments	Insert				9/14/2007 5:57 PM
Terminations	Termination Date	Insert				9/14/2007 5:57 PM
Terminations	Termination Effective Date	Insert				9/14/2007 5:57 PM
Terminations	Termination Reason	Insert				9/14/2007 5:57 PM