Covered Entity Details

DSH100075 ST JOSEPH'S HOSPITAL (Active) - information as of 5/14/2025 10:44:19 PM

Main Details

Name

ST JOSEPH'S HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH100075

Medicare Provider Number

100075

Additional Details

Current Program Status

Active

Registration Date

1/25/2008

Participating Start Date

4/1/2003

Participating Approval Date

1/25/2008

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Baycare Health System
Carl Tremonti, Chief Financial Officer
(813) 870-4020

Primary Contact

BayCare Health System
Kyle J Brauer, Manager, BayCare Pharmacy Supply Chain
(813) 901-6376

Addresses

Street Address

3001 WEST DR. M L KING JR BLVD
TAMPA, FL 33607

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
2/11/2010- ADDED FAX NUMBER FOR CONTACT.	02/11/2010

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	0100978-06	1881632818

Shipping Addresses

Shipping Address 1

ST JOSEPH'S HOSPITAL
3001 WEST DR. M L KING JR BLVD
TAMPA, FL 33607

Shipping Address 2

BayCare Integrated Service Center, LLC
Dba/ BayCare Central Pharmacy
7802 E. Telecom Parkway
Temple Terrace, FL 33637

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	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/15/2015	01/01/2016		09/07/2016
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/15/2015	01/01/2016		09/07/2016
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	10/15/2015	01/01/2016	01/01/2018	01/18/2018
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/11/2017	07/01/2017		04/11/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/15/2015	01/01/2016		09/07/2016
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/15/2015	01/01/2016		09/07/2016
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	10/15/2015	01/01/2016	05/31/2023	07/13/2023
Contract Detail	BAYCARE HOME CARE INC	8452 118TH AVE N		LARGO	FL	33773-5007	04/07/2015	07/01/2015		09/07/2016
Contract Detail	BAYCARE HOME CARE, INC.	D/B/A BAYCARE PHARMACY	3003 W DR MARTIN LUTHER KING JR. BLVD	TAMPA	FL	33607	10/10/2013	01/01/2014	10/14/2017	01/05/2018
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/15/2015	01/01/2016	02/01/2019	04/16/2019
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/15/2015	01/01/2016	02/01/2019	04/16/2019
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/15/2015	01/01/2016	02/01/2019	04/16/2019
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/15/2015	01/01/2016	02/01/2019	04/16/2019
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/15/2015	01/01/2016	02/01/2019	04/16/2019
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/15/2015	01/01/2016	02/01/2019	04/16/2019
Contract Detail	CENTERWELL PHARMACY, INC.	9843 WINDISCH RD		WEST CHESTER	OH	45069	07/16/2020	10/01/2020		10/01/2020
Contract Detail	CENTERWELL PHARMACY, INC.	10737 MARKS WAY		MIRAMAR	FL	33025	07/16/2020	10/01/2020		10/01/2020
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	01/12/2016	04/01/2016	09/14/2017	10/12/2017
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	10/15/2015	01/01/2016	08/09/2017	08/09/2017
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	06/30/2017	07/01/2017		06/30/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/19/2020	01/01/2021	07/01/2024	07/01/2024
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03930	611 S HOWARD AVE	TAMPA	FL	33606	04/14/2015	07/01/2015	02/01/2019	04/16/2019
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04701	6701 N. DALE MABRY HWY.	TAMPA	FL	33614	04/14/2015	07/01/2015	02/01/2019	04/16/2019
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/19/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	10/19/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/23/2024	07/01/2024		07/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	10/19/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	10/19/2020	01/01/2021		01/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	10/19/2020	01/01/2021		01/01/2021
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/07/2020	10/01/2020		10/01/2020
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/15/2015	01/01/2016	02/01/2019	04/16/2019
Contract Detail	PUBLIX PHARMACY #0399	7018 W WATERS AVE		TAMPA	FL	33634	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX PHARMACY #0524	3939 VAN DYKE ROAD		LUTZ	FL	33558	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX PHARMACY MARKETS	PUBLIX PHARMACY #0831	19221 NORTH DALE MABRY HIGHWAY	LUTZ	FL	33548	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0834	16560 N NEBRASKA AVE	LUTZ	FL	33549	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0129	1220 KINGSWAY RD	BRANDON	FL	33510	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0627	12139 WEST LINEBAUGH AVENUE	TAMPA	FL	33626	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0754	7835 GUNN HIGHWAY	TAMPA	FL	33626	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS INC	PUBLIX PHARMACY #0732	4854 SUN CITY CENTER BLVD	SUN CITY CENTER	FL	33573	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC	PUBLIX PHARMACY #1113	6434 U.S. HIGHWAY 41 NORTH	APOLLO BEACH	FL	33572	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1219	18901 STATE RD. 54	LUTZ	FL	33558	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY 1032	13154 US HIGHWAY 301 S	RIVERVIEW	FL	33578-7410	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1371	3863 SOUTH US HIGHWAY 301	RIVERVIEW	FL	33578	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #0582	2724 W HILLSBOROUGH AVE	TAMPA	FL	33614	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY 0611	1313 S DALE MABRY HWY	TAMPA	FL	33629-5010	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #0398	15151 NORTH DALE MABRY HWY	TAMPA	FL	33618	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1170	5371 EHRLICH ROAD	TAMPA	FL	33625	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1441	13178 NORTH DALE MABRY HWY	TAMPA	FL	33618	07/14/2017	10/01/2017	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX COMPOUNDING PHARMACY #3212	2424 ORLANDO CENTRAL PKWY STE 200	ORLANDO	FL	32809	07/14/2017	10/01/2017	04/01/2019	04/16/2019
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX CENTRAL PHARMACY #3201	2424 ORLANDO CENTRAL PARKWAY	ORLANDO	FL	32809	07/14/2017	10/01/2017	07/05/2020	01/14/2021
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #3221	3003 W. DR. MARTIN LUTHER KING JR. BLVD.	TAMPA	FL	33607	01/05/2018	04/01/2018	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #3220	620 10TH ST. N. SUITE 101	ST PETERSBURG	FL	33705	01/05/2018	04/01/2018	07/05/2020	07/05/2020
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #3213	1950 SAND LAKE RD, BLDG #5	ORLANDO	FL	32809	04/16/2019	07/01/2019	07/05/2020	01/14/2021
Contract Detail	WALGREEN CO	DBA: WALGREENS #10398	13911 NINE EAGLES DR	TAMPA	FL	33626	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO	DBA: WALGREENS #10484	5605 FISHHAWK CROSSING BLVD	LITHIA	FL	33547	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01925	13317 N BOULEVARD	TAMPA	FL	33612-3317	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02818	2199 W BUSCH BLVD	TAMPA	FL	33612	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02887	1001 78TH ST SOUTH	TAMPA	FL	33619	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02959	2111 E BUSCH BLVD	TAMPA	FL	33612	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02975	15602 N. DALE MABRY	TAMPA	FL	33618	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03128	5709 GUNN HIGHWAY	TAMPA	FL	33625	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03145	1860 E. FOWLER AVE.	TAMPA	FL	33612	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03351	6818 N. ARMENIA AVE.	TAMPA	FL	33604	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03459	2117 E HILLSBOROUGH AVE	TAMPA	FL	33610	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03743	4651 W. KENNEDY BLVD.	TAMPA	FL	33609	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03744	4738 W. GANDY BLVD.	TAMPA	FL	33611	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03829	8398 SHELDON ROAD	TAMPA	FL	33615	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03863	4141 W HILLSBOROUGH AVE	TAMPA	FL	33614	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04326	4319 N. ARMENIA AVE.	TAMPA	FL	33607	10/15/2015	01/01/2016	03/05/2018	05/08/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04523	930 PROVIDENCE ROAD	BRANDON	FL	33511	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04573	9202 N. 56TH STREET	TEMPLE TERRACE	FL	33617	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05451	315 W. PLATT STREET	TAMPA	FL	33606	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05576	7925 GUNN HIGHWAY	TAMPA	FL	33626	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05806	3917 NORTH NEBRASKA AVE	TAMPA	FL	33603	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06029	11115 E DR MLK JR BLVD	SEFFNER	FL	33584	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06192	6503 W WATERS AVE	TAMPA	FL	33634-2207	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06412	28115 WESLEY CHAPEL BLVD	WESLEY CHAPEL	FL	33543	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12673	2916 E. FLETCHER AVE.	TAMPA	FL	33612	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06494	22829 STATE ROAD 54	LAND O LAKES	FL	34639	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06674	8706 W HILLSBOROUGH AVE	TAMPA	FL	33615-3705	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06732	2102 W BAKER STREET	PLANT CITY	FL	33563-1643	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07569	20741 BRUCE B DOWNS BLVD	TAMPA	FL	33647	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07815	3016 W GANDY BLVD	TAMPA	FL	33611	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09300	3890 VAN DYKE RD	LUTZ	FL	33548	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09475	10624 GIBSONTON DRIVE	RIVERVIEW	FL	33578	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11246	7827 LAND O LAKES BLVD	LAND O LAKES	FL	34638	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 13031	3863 S DALE MABRY HWY	TAMPA	FL	33611	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 13824	18511 N. US HWY 41	LUTZ	FL	33549	10/15/2015	01/01/2016	03/05/2018	03/14/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 15129	3518 HENDERSON BLVD	TAMPA	FL	33609	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15236	13130 N DALE MABRY HWY	TAMPA	FL	33618-2406	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS SPECIALTY PHARMACY #12146	1200 KUHL AVE	ORLANDO	FL	32806	10/15/2015	01/01/2016	04/30/2020	05/05/2020
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #13072	8333 N DAVIS HWY STE 50	PENSACOLA	FL	32514	10/15/2015	01/01/2016	04/30/2020	05/08/2020
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	10/15/2015	01/01/2016		09/07/2016
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	10/15/2015	01/01/2016	10/01/2021	07/20/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	10/15/2015	01/01/2016		09/07/2016
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	10/15/2015	01/01/2016		09/07/2016

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH100075A	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL- NORTH	4211 VAN DYKE ROAD	LUTZ	FL	Terminated
DSH100075AA	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL SOUTH Respiratory Care Services	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AB	Child	DSH	ST JOSEPH'S HOSPITAL	St Josephs Hospital South MRI	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AC	Child	DSH	ST JOSEPH'S HOSPITAL	St. Josephs Hospital South CT Scan	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AD	Child	DSH	ST JOSEPH'S HOSPITAL	St. Josephs Hospital South Nuclear Medicine	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AE	Child	DSH	ST JOSEPH'S HOSPITAL	St. Josephs Hospital South Interventional Services	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AF	Child	DSH	ST JOSEPH'S HOSPITAL	St. Josephs Hosptial South Diagnostic Imagining	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AG	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL South Ultrasound	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AH	Child	DSH	ST JOSEPH'S HOSPITAL	Rehab Services Main	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AJ	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL SOUTH Breast Center	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AK	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL SOUTH Anesthesiology	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AL	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL SOUTH Labor and Delivery	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AM	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL SOUTH Post Anesthesia Care Unit	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AN	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL SOUTH Endoscopy	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AP	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL SOUTH Surgery	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075AQ	Child	DSH	ST JOSEPH'S HOSPITAL	Outpatient Infusion Center	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AR	Child	DSH	ST JOSEPH'S HOSPITAL	Hemodialysis	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AS	Child	DSH	ST JOSEPH'S HOSPITAL	Non-Invasive Cardiology	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AT	Child	DSH	ST JOSEPH'S HOSPITAL	Endoscopy	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AU	Child	DSH	ST JOSEPH'S HOSPITAL	Respiratory Care Services	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AV	Child	DSH	ST JOSEPH'S HOSPITAL	Nuclear Medicine	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AW	Child	DSH	ST JOSEPH'S HOSPITAL	Diagnostic Imaging	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AX	Child	DSH	ST JOSEPH'S HOSPITAL	Ultrasound	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AY	Child	DSH	ST JOSEPH'S HOSPITAL	BREAST CENTER	4211 VAN DYKE RD	LUTZ	FL	Active
DSH100075AZ	Child	DSH	ST. JOSEPHS HOSPITAL	ST. JOSEPHS HOSPITAL SOUTH Surgery	4211 VAN DYKE RD	LUTZ	FL	Terminated
DSH100075B	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / EMERGENCY SERVICE	4211 VAN DYKE ROAD	Lutz	FL	Active
DSH100075BA	Child	DSH	ST JOSEPH'S HOSPITAL	Specialty Pharmacy Clinic - Specialty Pharmacy Clinic	3030 W Martin Luther King Jr Blvd	Tampa	FL	Active
DSH100075BB	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL - SOUTH - St. Joseph's Hospital South Rehab Services	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075BC	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL - SOUTH - St. Joseph's Hospital South Non-invasive Cardiology	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075BD	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital Infusion Center - Outpatient Infusion Adult	4510 N Habana Ave	Tampa	FL	Active
DSH100075BE	Child	DSH	ST JOSEPH'S HOSPITAL	SJH HEMATOLOGY & ONCOLOGY - SJH Hem Onc Habana	4620 N HABANA AVE	TAMPA	FL	Active
DSH100075BF	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL RHEUMATOLOGY - SJH Rheum St Petersburg	620 10TH ST N	ST PETERSBURG	FL	Approved
DSH100075BG	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL NEUROLOGY - SJH Neuro St Petersburg	1201 5TH AVE N	ST PETERSBURG	FL	Approved
DSH100075BH	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INFUSION CTR - Outpatient Infusion Clearwater	400 PINELLAS ST	CLEARWATER	FL	Approved
DSH100075BJ	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INFUSION CTR - Outpatient Infusion St Pete Satellite	1200 7TH AVE N	ST PETERSBURG	FL	Approved
DSH100075BK	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INFUSION CTR - Outpatient Infusion Safety Harbor	1840 MEASE DR	SAFETY HARBOR	FL	Approved
DSH100075BL	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital Hematology & Oncology - SJH Hem Onc St Petersburg	620 10th St N	St. Petersburg	FL	Approved
DSH100075BM	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INFUSION CTR - Outpatient Infusion St Pete	620 10TH ST N	ST PETERSBURG	FL	Approved
DSH100075C	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / ANESTHESIOLOGY	4211 Van Dyke Road	Lutz	FL	Active
DSH100075D	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / BLOOD SERVICES	4211 VAN DYKE ROAD	Lutz	FL	Terminated
DSH100075E	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / CT SCAN	4211 VAN DYKE ROAD	Lutz	FL	Active
DSH100075F	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / INTERVENTIONAL SERVICES	4211 VAN DYKE ROAD	Lutz	FL	Active
DSH100075G	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / MRI	4211 VAN DYKE ROAD	Lutz	FL	Active
DSH100075H	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / Surgery	4211 VAN DYKE ROAD	Lutz	FL	Active
DSH100075J	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / INTENSIVE CARE UNIT I	4211 VAN DYKE ROAD	Lutz	FL	Terminated
DSH100075K	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / LABOR & DELIVERY	4211 VAN DYKE ROAD	Lutz	FL	Active
DSH100075L	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital - North / PACU	4211 VAN DYKE ROAD	Lutz	FL	Active
DSH100075M	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / SURGERY WOMENS	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075N	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / PACU Women's	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075P	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / MRI Womens	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075Q	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / ULTRASOUND WOMENS	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075R	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / CT SCAN WOMENS	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075S	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / DIAGNOSTIC IMAGING WOMENS	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075T	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / RESPIRATORY CARE SVCS WOMENS	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075U	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / WOMENS MATERNAL FETAL MED CTR	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Terminated
DSH100075V	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / WOMENS URGENT CARE	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075W	Child	DSH	ST JOSEPH'S HOSPITAL	ST JOSEPH'S HOSPITAL INC / BREAST CENTER WOMENS	3030 W DR MARTIN LUTHER KING JR BLVD	TAMPA	FL	Active
DSH100075X	Child	DSH	ST JOSEPH'S HOSPITAL	St. Joseph's Hospital South Emergency Services	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075Y	Child	DSH	ST JOSEPH'S HOSPITAL	ST. JOSEPHS HOSPITAL South Outpatient Infusion	6901 SIMMONS LOOP	RIVERVIEW	FL	Active
DSH100075Z	Child	DSH	ST JOSEPH'S HOSPITAL	St. Josephs Hosptial South Hemodialysis	6901 SIMMONS LOOP	RIVERVIEW	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/13/2023 10:58:25 AM	8/26/2024 11:51:05 AM	8/26/2024 11:51 AM
Details	Last Recertification Date	Update	Recertification	9/16/2022 10:26:15 AM	9/13/2023 10:58:25 AM	9/13/2023 10:58 AM
Details	Last Recertification Date	Update	Recertification	9/1/2021 8:09:46 AM	9/16/2022 10:26:15 AM	9/16/2022 10:26 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 9:02:32 AM	9/1/2021 8:09:46 AM	9/1/2021 8:09 AM
Medicaid Billing	NPI: State	Update	Recertification		FL	9/8/2020 9:02 AM
Details	Last Recertification Date	Update	Recertification	9/17/2019 2:30:41 PM	9/8/2020 9:02:32 AM	9/8/2020 9:02 AM
Contacts	Primary Contact	Update	Change Request	Magee, Michael Vice President of Pharmacy BayCare Health System 8138704020	Brauer, Kyle J Manager, BayCare Pharmacy Supply Chain BayCare Health System 8139016376	6/5/2020 7:12 AM
Details	Last Recertification Date	Update	Recertification	8/31/2018 8:09:26 AM	9/17/2019 2:30:41 PM	9/17/2019 2:30 PM
Details	Last Recertification Date	Update	Recertification	11/9/2017 8:42:57 AM	8/31/2018 8:09:26 AM	8/31/2018 8:09 AM
Addresses	Shipping Address	Insert	Change Request		ST JOSEPH'S HOSPITAL 3001 WEST DR. M L KING JR BLVD TAMPA, FL 33607	8/8/2018 4:02 PM
Addresses	Shipping Address	Insert	Change Request		BayCare Integrated Service Center, LLC Dba/ BayCare Central Pharmacy 7802 E. Telecom Parkway Temple Terrace, FL 33637	8/8/2018 4:02 PM
Details	Last Recertification Date	Update	Recertification	8/26/2016 12:00:00 AM	11/9/2017 8:42:57 AM	11/9/2017 8:42 AM
Contacts	Authorizing Official	Update		Tremonti, Carl Chief Financial Officer 8138704020	Tremonti, Carl Chief Financial Officer Baycare Health System 8138704020	10/2/2017 2:52 PM
Contacts	Primary Contact	Update		Magee, Michael Vice President of Pharmacy 8138704020	Magee, Michael Vice President of Pharmacy BayCare Health System 8138704020	10/1/2017 6:33 PM
Contacts	Authorizing Official	Insert			Tremonti, Carl Chief Financial Officer 8138704020	8/9/2017 10:58 AM
Contacts	Primary Contact	Insert			Magee, Michael Vice President of Pharmacy 8138704020	8/4/2017 1:11 PM
Addresses	Main Address	Insert			3001 WEST DR. M L KING JR BLVD TAMPA, FL 33607	9/7/2016 2:35 PM
Details	Last Recertification Date	Update		8/31/2015 12:00:00 AM	8/26/2016 12:00:00 AM	9/2/2016 8:02 AM
Medicaid Billing	NPI: Number	Insert			1881632818	10/15/2015 3:02 PM
Details	Last Recertification Date	Update		8/19/2014 12:00:00 AM	8/31/2015 12:00:00 AM	8/31/2015 11:29 AM
Details	Last Recertification Date	Update		8/26/2013 12:00:00 AM	8/19/2014 12:00:00 AM	8/19/2014 11:31 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/26/2013 12:00:00 AM	8/26/2013 6:27 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/2/2012 8:00 AM
Medicaid Billing	Medicaid: Number	Update		0100978	0100978-06	4/12/2012 12:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/4/2012 2:17 PM
Medicaid Billing	Medicaid: Number	Insert			0100978	4/4/2012 2:17 PM
Medicaid Billing	Medicaid: State	Insert			FL	4/4/2012 2:17 PM
Details	Last Recertification Date	Insert				2/11/2010 5:38 PM
Details	Grant Number	Insert				2/11/2010 5:38 PM
Details	340B ID	Insert			DSH100075	2/11/2010 5:38 PM
Details	Is Authorizing Official EHB Data	Insert				2/11/2010 5:38 PM
Dates	Last Date That 340B Drugs Purchased	Insert				2/11/2010 5:38 PM
Details	Medicare Provider Number	Insert			100075	2/11/2010 5:38 PM
Details	Entity Name	Insert			ST JOSEPH'S HOSPITAL	2/11/2010 5:38 PM
Details	Program Code	Insert			DSH	2/11/2010 5:38 PM
Details	Entity Subname	Insert				2/11/2010 5:38 PM
Dates	Participating Approval Date	Insert			1/25/2008 12:00:00 AM	2/11/2010 5:38 PM
Details	State	Insert			Active	2/11/2010 5:38 PM
Dates	Registration Date	Insert			1/25/2008 12:00:00 AM	2/11/2010 5:38 PM
Dates	Signed By Date	Insert				2/11/2010 5:38 PM
Dates	Start Date	Insert			4/1/2003 12:00:00 AM	2/11/2010 5:38 PM
Terminations	Termination Comments	Insert				2/11/2010 5:38 PM
Terminations	Termination Date	Insert				2/11/2010 5:38 PM
Terminations	Termination Effective Date	Insert				2/11/2010 5:38 PM
Terminations	Termination Reason	Insert				2/11/2010 5:38 PM
Details	Comments Public	Insert			2/11/2010- ADDED FAX NUMBER FOR CONTACT.	2/11/2010 5:38 PM