Covered Entity Details

DSH100022L JACKSON HEALTH SYSTEM (Active) - information as of 4/25/2025 6:36:13 PM

Main Details

Name

JACKSON HEALTH SYSTEM

Subdivision Name

JACKSON SOUTH COMMUNITY HOSPITAL

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH100022L

Medicare Provider Number

100022

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

9/17/2008

Participating Start Date

9/18/2008

Participating Approval Date

9/18/2008

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Jackson Health System
Carlos A. Migoya, CEO
(305) 585-6754

Primary Contact

Jackson Health System
VENESSA GOODNOW, AVP & CHIEF PHARMACY OFFICER
(305) 585-7411

Addresses

Street Address

9333 SW 152ND STREET
MIAMI, FL 33157

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
FL	010042136	1174601397

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
DSH100022A	Child	DSH	JACKSON HEALTH SYSTEM	PUBLIC HEALTH TRUST OF DADE COUNTY NORTH DADE HEALTH CENTER	16555 N.W. 25TH AVE	Opa Locka	FL	Active
DSH100022AA	Child	DSH	JACKSON HEALTH SYSTEM	JNMC EMERGENCY DEPARTMENT	160 NW 170 STREET	NORTH MIAMI BEACH	FL	Active
DSH100022AB	Child	DSH	JACKSON HEALTH SYSTEM	Miami Transplant Institute	1801 NW 9th Avenue	Miami	FL	Active
DSH100022AC	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON URGENT CARE-COUNTRY WALK	13707 SW 152 STREET	MIAMI	FL	Terminated
DSH100022AD	Child	DSH	JACKSON HEALTH SYSTEM	Jackson North Medical Center - Surgery Separate	160 NW 170 St	North Miami Beach	FL	Active
DSH100022AE	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Ambulatory Surgery	9333 SW 152nd St	Miami	FL	Active
DSH100022AF	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Ultrasonic Unit	9333 SW 152nd St	Miami	FL	Terminated
DSH100022AG	Child	DSH	JACKSON HEALTH SYSTEM	Jackson North Medical Center - Ultrasound	160 NW 170 St	North Miami Beach	FL	Terminated
DSH100022AH	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Surgery Unit	9333 152nd St	Miami	FL	Active
DSH100022AJ	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Nuclear Medicine	9333 SW 152nd St	Miami	FL	Active
DSH100022AK	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - JS Trauma OR	9333 SW 152nd St	Miami	FL	Active
DSH100022AL	Child	DSH	JACKSON HEALTH SYSTEM	Jackson Memorial Hospital - Ryder Trauma Center - Ryder Trauma Center	1800 NW 10th Ave	Miami	FL	Active
DSH100022AM	Child	DSH	JACKSON HEALTH SYSTEM	Jackson North Medical Center - Delivery Room	160 NW 170 St	North Miami Beach	FL	Active
DSH100022AN	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER - MRI	160 NW 170TH STREET	NORTH MIAMI BEACH	FL	Terminated
DSH100022AP	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Anesthesia Unit	9333 SW 152nd St	Miami	FL	Terminated
DSH100022AQ	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Respiratory Therapy Unit	9333 SW 152nd St	Miami	FL	Active
DSH100022AR	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - MRI Unit	9333 SW 152nd St	Miami	FL	Terminated
DSH100022AS	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Cardiac	9333 SW 152nd St	Miami	FL	Active
DSH100022AT	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - JS Intake	9333 SW 152nd St	Miami	FL	Active
DSH100022AU	Child	DSH	JACKSON HEALTH SYSTEM	Jackson North Medical Center - Anesthesia	160 NW 170 St	North Miami Beach	FL	Terminated
DSH100022AV	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER - Nuclear Medicine	160 NW 170TH STREET	NORTH MIAMI BEACH	FL	Active
DSH100022AW	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER - Dialysis	160 NW 170TH STREET	NORTH MIAMI BEACH	FL	Active
DSH100022AX	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Interventional Radiology	9333 SW 152nd St	Miami	FL	Terminated
DSH100022AY	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - EKG Cardiopulmonary	9333 SW 152nd St	Miami	FL	Terminated
DSH100022AZ	Child	DSH	JACKSON HEALTH SYSTEM	Jackson North Medical Center - Recovery Separate	160 NW 170 St	North Miami Beach	FL	Active
DSH100022B	Child	DSH	JACKSON HEALTH SYSTEM	MENTAL HEALTH HOSPITAL CENTER	1695 N.W. 9TH AVENUE	MIAMI	FL	Active
DSH100022BA	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER - Non Invasive Vascular	160 NW 170TH STREET	NORTH MIAMI BEACH	FL	Terminated
DSH100022BB	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Hemo Dialysis Unit	9333 SW 152nd St	Miami	FL	Active
DSH100022BC	Child	DSH	JACKSON HEALTH SYSTEM	Jackson Urgent Care - UCC Cutler Bay - UCC Cutler Bay	18910 South Dixie Highway	Cutler Bay	FL	Terminated
DSH100022BD	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Radiology	9333 SW 152nd St	Miami	FL	Active
DSH100022BE	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - JS Comprehensive Breast Center	9333 SW 152nd St	Miami	FL	Terminated
DSH100022BF	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - JS Trauma ER	9333 SW 152nd St	Miami	FL	Active
DSH100022BG	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER - Endoscopy	160 NW 170TH STREET	NORTH MIAMI BEACH	FL	Active
DSH100022BH	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Endoscopy	9333 SW 152nd St	Miami	FL	Active
DSH100022BJ	Child	DSH	JACKSON HEALTH SYSTEM	Jackson North Medical Center - CT Scanner	160 NW 170 St	North Miami Beach	FL	Active
DSH100022BK	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER - Interventional Radiology	160 NW 170TH STREET	NORTH MIAMI BEACH	FL	Active
DSH100022BL	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Labor & Delivery	9333 SW 152nd St	Miami	FL	Terminated
DSH100022BM	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Neurosurgery Clinic	9333 SW 152nd St	Miami	FL	Terminated
DSH100022BN	Child	DSH	JACKSON HEALTH SYSTEM	Jackson Urgent Care - UCC Keystone Point - UCC Keystone Point	13120 Biscayne Blvd	North Miami	FL	Terminated
DSH100022BP	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER - Respiratory Therapy	160 NW 170TH STREET	NORTH MIAMI BEACH	FL	Active
DSH100022BQ	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER - Cardiovascular Cath Lab	160 NW 170TH STREET	NORTH MIAMI BEACH	FL	Active
DSH100022BR	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Cat Scan Unit	9333 SW 152nd St	Miami	FL	Active
DSH100022BS	Child	DSH	JACKSON HEALTH SYSTEM	Jackson South Community Hospital - Recovery Unit	9333 SW 152nd St	Miami	FL	Active
DSH100022BT	Child	DSH	JACKSON HEALTH SYSTEM	Jackson Health System - JNMC Multi-Specialty Clinic	100 N.W. 170th Street	Miami	FL	Terminated
DSH100022BU	Child	DSH	JACKSON HEALTH SYSTEM	Jackson Health System - MTI Clinic Plantation	600 S Pine Island Rd	Plantation	FL	Active
DSH100022BV	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Electroencephalograph(EEG)	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022BW	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Physical Therapy	2801 NW 79TH AVE	Doral	FL	Terminated
DSH100022BX	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-X-Ray	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022BY	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JNMHC PHYSICAL THERAPY#1	160 NW 170TH ST	NORTH MIAMI BEACH	FL	Terminated
DSH100022BZ	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-CT Scan	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022C	Child	DSH	JACKSON HEALTH SYSTEM	JEFFERSON REAVES SR HLTH CTR	1009 NW 5TH AVENUE	MIAMI	FL	Active
DSH100022CA	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Anesthesia	2801 NW 79TH AVE	DORAL	FL	Terminated
DSH100022CB	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Nuclear Medicine	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022CC	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JS Multispecialty Clinic	9333 SW 152ND STREET	Miami	FL	Terminated
DSH100022CD	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-MRI	2801 NW 79TH AVE	DORAL	FL	Terminated
DSH100022CE	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - Jackson South Community Hospital- OB Triage	9333 SW 152nd St	Miami	FL	Active
DSH100022CF	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Pathology	2801 NW 79TH AVE	DORAL	FL	Terminated
DSH100022CG	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Hybrid Room	2801 NW 79TH AVE	Doral	FL	Active
DSH100022CH	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Dialysis	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022CJ	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-GI Station	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022CK	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - Jackson South Community Hospital- Laboratory	9333 SW 152nd St	Miami	FL	Active
DSH100022CL	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Echocardiography	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022CM	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Operating Room	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022CN	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Laboratory	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022CP	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Respiratory Therapy	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022CQ	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Ultrasound	2801 NW 79TH AVE	DORAL	FL	Terminated
DSH100022CR	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON HEALTH SYSTEM - JW-Emergency Room	2801 NW 79TH AVE	DORAL	FL	Active
DSH100022F	Child	DSH	JACKSON HEALTH SYSTEM	STOCKADE DETENTION CENTER	6950 NW 41ST STREET	MIAMI	FL	Active
DSH100022H	Child	DSH	JACKSON HEALTH SYSTEM	TURNER GUILFORD KNIGHT CENTER	7000 NW 41ST STREET	MIAMI	FL	Active
DSH100022I	Child	DSH	JACKSON HEALTH SYSTEM	METRO WEST DETENTION CENTER	13850 NW 41ST STREET	MIAMI	FL	Active
DSH100022J	Child	DSH	JACKSON HEALTH SYSTEM	PRE-TRIAL DETENTION CENTER OF DADE COUNTY	1321 NW 13TH STREET	MIAMI	FL	Active
DSH100022L	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON SOUTH COMMUNITY HOSPITAL	9333 SW 152ND STREET	MIAMI	FL	Active
DSH100022M	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON NORTH MEDICAL CENTER	160 NW 170 STREET	NORTH MIAMI BEACH	FL	Active
DSH100022N	Child	DSH	JACKSON HEALTH SYSTEM	PUBLIC HEALTH TRUST OF DADE	PETS HEALTH CENTER	MIAMI BEACH	FL	Active
DSH100022P	Child	DSH	JACKSON HEALTH SYSTEM	ROSIE LEE WESLEY HEALTH CENTER	6601 SW 62ND AVE	MIAMI	FL	Active
DSH100022Q	Child	DSH	JACKSON HEALTH SYSTEM	PUBLIC HEALTH TRUST OF DADE COUNTY	PHT/ RAFAEL A PENALVER CLINIC	MIAMI	FL	Active
DSH100022R	Child	DSH	JACKSON HEALTH SYSTEM	PUBLIC HEALTH TRUST OF MIAMI-DADE COUNTY SOUTH DADE HOMELESS ASSISTANCE CENTER CLINIC	28205 SW 124th Ct.	HOMESTEAD	FL	Active
DSH100022S	Child	DSH	JACKSON MEMORIAL	PHT DR RAFAEL A PENALVER CLINIC	971 NW 2ND AVENUE	MIAMI	FL	Terminated
DSH100022T	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON SOUTH EMERGENCY DEPARTMENT	9333 SW 152ND STREET	MIAMI	FL	Active
DSH100022U	Child	DSH	JACKSON HEALTH SYSTEM	JBHH ED EMERGENCY SERVICES	1695 NW 9TH AVE	MIAMI	FL	Active
DSH100022V	Child	DSH	JACKSON HEALTH SYSTEM	JBHH ADULT OUTPATIENT CENTER (AOC)	1695 NW 9TH AVE	MIAMI	FL	Active
DSH100022W	Child	DSH	JACKSON HEALTH SYSTEM	JBHH CHILD AND ADOLESCENT CENTER (CAC)	1695 NW 9TH AVE	MIAMI	FL	Active
DSH100022X	Child	DSH	JACKSON HEALTH SYSTEM	JACKSON SOUTH WOUND CARE CENTER	9333 SW 152ND STREET	MIAMI	FL	Terminated
DSH100022Y	Child	DSH	JACKSON HEALTH SYSTEM	JNMC NURSING SERVICES	160 NW 170 STREET	NORTH MIAMI BEACH	FL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/6/2023 4:05:45 PM	8/29/2024 1:36:19 PM	8/29/2024 1:36 PM
Contacts	Primary Contact	Update	Profile Change Request	PRICE, VENESSA DIRECTOR OF PHARMACY Jackson Health System 3055857411	GOODNOW, VENESSA AVP & CHIEF PHARMACY OFFICER Jackson Health System 3055857411	2/7/2024 1:01 PM
Details	Last Recertification Date	Update	Recertification	9/14/2022 4:59:58 PM	9/6/2023 4:05:45 PM	9/6/2023 4:05 PM
Details	Last Recertification Date	Update	Recertification	9/2/2021 10:56:30 AM	9/14/2022 4:59:58 PM	9/14/2022 4:59 PM
Details	Last Recertification Date	Update	Recertification	8/27/2020 4:11:47 PM	9/2/2021 10:56:30 AM	9/2/2021 10:56 AM
Contacts	Authorizing Official	Update		Migoya, Carlos A. CEO Jackson Health System 3055856754	Migoya, Carlos A. CEO Jackson Health System 3055856754	7/13/2021 3:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1174601397	8/27/2020 4:11 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/27/2020 4:11 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1174601397 ( )		8/27/2020 4:11 PM
Details	Last Recertification Date	Update	Recertification	9/4/2019 12:09:01 PM	8/27/2020 4:11:47 PM	8/27/2020 4:11 PM
Details	Last Recertification Date	Update	Recertification	9/10/2018 2:38:18 PM	9/4/2019 12:09:01 PM	9/4/2019 12:09 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 10:19:10 AM	9/10/2018 2:38:18 PM	9/10/2018 2:38 PM
Details	Last Recertification Date	Update	Recertification	9/2/2016 12:00:00 AM	12/5/2017 10:19:10 AM	12/5/2017 10:19 AM
Contacts	Authorizing Official	Update		Migoya, Carlos A. CEO 3055856754	Migoya, Carlos A. CEO Jackson Health System 3055856754	10/11/2017 2:17 PM
Contacts	Primary Contact	Update		PRICE, VENESSA DIRECTOR OF PHARMACY 3055857411	PRICE, VENESSA DIRECTOR OF PHARMACY Jackson Health System 3055857411	10/11/2017 12:49 PM
Contacts	Primary Contact	Insert			PRICE, VENESSA DIRECTOR OF PHARMACY 3055857411	7/13/2017 2:20 PM
Contacts	Authorizing Official	Update		ROLDAN, ENEIDA PRESIDENT/CEO 3055856754	Migoya, Carlos A. CEO 3055856754	7/13/2017 2:20 PM
Addresses	Main Address	Insert			9333 SW 152ND STREET MIAMI, FL 33157	5/11/2017 1:17 PM
Details	Last Recertification Date	Update		9/9/2015 12:00:00 AM	9/2/2016 12:00:00 AM	9/2/2016 11:11 AM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	9/9/2015 2:32 PM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	9/9/2015 12:00:00 AM	9/9/2015 2:32 PM
Details	Last Recertification Date	Update		9/6/2013 3:51:53 PM	9/3/2014 12:00:00 AM	9/3/2014 12:35 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/6/2013 3:51:53 PM	9/6/2013 3:51 PM
Medicaid Billing	NPI: Number	Insert			1174601397	9/17/2012 10:00 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/25/2012 10:38 AM
Contacts	Authorizing Official	Insert			ROLDAN, ENEIDA PRESIDENT/CEO 3055856754	12/19/2011 5:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	9/17/2008 9:39 AM
Medicaid Billing	Medicaid: Number	Insert			010042136	9/17/2008 9:39 AM
Medicaid Billing	Medicaid: State	Insert			FL	9/17/2008 9:39 AM
Details	Last Recertification Date	Insert				9/17/2008 9:39 AM
Details	Grant Number	Insert				9/17/2008 9:39 AM
Details	340B ID	Insert			DSH100022L	9/17/2008 9:39 AM
Details	Is Authorizing Official EHB Data	Insert				9/17/2008 9:39 AM
Dates	Last Date That 340B Drugs Purchased	Insert				9/17/2008 9:39 AM
Details	Medicare Provider Number	Insert			100022	9/17/2008 9:39 AM
Details	Entity Name	Insert			JACKSON HEALTH SYSTEM	9/17/2008 9:39 AM
Details	Program Code	Insert			DSH	9/17/2008 9:39 AM
Details	Entity Subname	Insert			JACKSON SOUTH COMMUNITY HOSPITAL	9/17/2008 9:39 AM
Dates	Participating Approval Date	Insert			9/18/2008 12:00:00 AM	9/17/2008 9:39 AM
Details	State	Insert			Active	9/17/2008 9:39 AM
Dates	Registration Date	Insert			9/17/2008 12:00:00 AM	9/17/2008 9:39 AM
Dates	Signed By Date	Insert			8/26/2008 12:00:00 AM	9/17/2008 9:39 AM
Dates	Start Date	Insert			9/18/2008 12:00:00 AM	9/17/2008 9:39 AM
Terminations	Termination Comments	Insert				9/17/2008 9:39 AM
Terminations	Termination Date	Insert				9/17/2008 9:39 AM
Terminations	Termination Effective Date	Insert				9/17/2008 9:39 AM
Terminations	Termination Reason	Insert				9/17/2008 9:39 AM