| Addresses | Main Address | Update | Change Request |
13400 SW 120 Street
Miami, FL 33186 |
13400 SW 120th Street
Suite 100
Miami, FL 33186 | 3/11/2025 12:28 PM |
| Addresses | Billing Address | Update | Change Request | Nicklaus Children's Hospital
3100 SW 62 Avenue
Miami, FL 33155 | Nicklaus Children's Hospital
3100 SW 62nd Avenue
Miami, FL 33155 | 3/11/2025 12:28 PM |
| Addresses | Shipping Address | Update | Change Request | Nicklaus Children's Hospital
3100 SW 62 Avenue
Miami, FL 33155 | Nicklaus Children's Hospital
3100 SW 62nd Avenue
Miami, FL 33155 | 3/11/2025 12:28 PM |
| Contacts | Authorizing Official | Update | Change Request | Reed, Perry Ann
COO & President
NIcklaus Children's Health System
7866242032 | Javersack, Dawn
Sr. Vice President and Chief Financial Officer
Nicklaus Children's Health System
7866242005 | 1/27/2025 7:44 AM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2023 2:51:04 PM | 8/27/2024 10:35:47 AM | 8/27/2024 10:35 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 5/7/2024 1:25 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 10060934 | 5/7/2024 1:25 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | FL | 5/7/2024 1:25 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1811141633 | 5/7/2024 1:25 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | FL | 5/7/2024 1:25 PM |
| Details | Last Recertification Date | Update | Recertification | 9/8/2022 9:08:54 AM | 9/8/2023 2:51:04 PM | 9/8/2023 2:51 PM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2021 1:33:06 PM | 9/8/2022 9:08:54 AM | 9/8/2022 9:08 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2020 9:10:39 AM | 8/26/2021 1:33:06 PM | 8/26/2021 1:33 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1871540237 | 8/21/2020 9:10 AM |
| Medicaid Billing | NPI: State | Insert | Recertification | | FL | 8/21/2020 9:10 AM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1871540237 ( ) | | 8/21/2020 9:10 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2019 2:53:13 PM | 8/21/2020 9:10:39 AM | 8/21/2020 9:10 AM |
| Contacts | Authorizing Official | Update | Change Request | Perdomo, Jose
Interim President and COO
Nicklaus Children's Hospital
3056666511-2010 | Reed, Perry Ann
COO & President
NIcklaus Children's Health System
7866242032 | 7/29/2020 8:21 AM |
| Details | Last Recertification Date | Update | Recertification | 9/6/2018 9:04:08 AM | 8/26/2019 2:53:13 PM | 8/26/2019 2:53 PM |
| Contacts | Primary Contact | Update | Change Request | Bastida, Acirema
Pharmacy 340B Analyst
Nicklaus Children's Hospital
7866245789 | Bastida, Acirema
Pharmacy 340B Analyst
Nicklaus Children's Hospital
7866245789 | 8/2/2019 10:33 AM |
| Contacts | Authorizing Official | Update | Change Request | Harrington, Michael
President-COO
Nicklaus Children's Hospital
3056666511-2010 | Perdomo, Jose
Interim President and COO
Nicklaus Children's Hospital
3056666511-2010 | 5/8/2019 8:59 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Bastida, Acirema
Supervisor Pharmacy Business & 340B
Nicklaus Children's Hospital
7866245789 | Bastida, Acirema
Pharmacy 340B Analyst
Nicklaus Children's Hospital
7866245789 | 5/6/2019 8:16 AM |
| Details | Last Recertification Date | Update | Recertification | 11/8/2017 11:11:56 AM | 9/6/2018 9:04:08 AM | 9/6/2018 9:04 AM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2016 12:00:00 AM | 11/8/2017 11:11:56 AM | 11/8/2017 11:11 AM |
| Contacts | Authorizing Official | Update | | Harrington, Michael
President-COO
3056666511-2010 | Harrington, Michael
President-COO
Nicklaus Children's Hospital
3056666511-2010 | 11/8/2017 10:44 AM |
| Contacts | Primary Contact | Update | | Bastida, Acirema
Supervisor Pharmacy Business & 340B
7866245789 | Bastida, Acirema
Supervisor Pharmacy Business & 340B
Nicklaus Children's Hospital
7866245789 | 10/20/2017 1:50 PM |
| Addresses | Main Address | Insert | | |
13400 SW 120 Street
Miami, FL 33186 | 7/21/2017 4:44 PM |
| Addresses | Billing Address | Insert | | | Nicklaus Children's Hospital
3100 SW 62 Avenue
Miami, FL 33155 | 7/21/2017 4:44 PM |
| Addresses | Shipping Address | Insert | | | Nicklaus Children's Hospital
3100 SW 62 Avenue
Miami, FL 33155 | 7/21/2017 4:44 PM |
| Contacts | Signed By | Insert | | | McGill, Martha
EVP,COO
3056685523 | 7/21/2017 4:44 PM |
| Contacts | Authorizing Official | Insert | | | Harrington, Michael
President-COO
3056666511-2010 | 7/21/2017 4:44 PM |
| Contacts | Primary Contact | Update | | Alfonso, Irvin
Director of Pharmacy
3056666511-8512 | Bastida, Acirema
Supervisor Pharmacy Business & 340B
7866245789 | 7/21/2017 4:44 PM |
| Contacts | Primary Contact | Insert | | | Alfonso, Irvin
Director of Pharmacy
3056666511-8512 | 8/31/2016 10:02 AM |
| Details | Last Recertification Date | Update | | 8/10/2015 12:00:00 AM | 8/31/2016 12:00:00 AM | 8/31/2016 10:02 AM |
| Details | Last Recertification Date | Update | | 8/19/2014 12:00:00 AM | 8/10/2015 12:00:00 AM | 8/10/2015 2:18 PM |
| Details | Entity Name | Update | | Miami Children's Hospital | Nicklaus Children's Hospital | 7/29/2015 10:59 AM |
| Details | Entity Subname | Update | | West Kendall Outpatient Center | Nicklaus Children's West Kendall Outpatient Center | 7/29/2015 10:59 AM |
| Details | Last Recertification Date | Update | | | 8/19/2014 12:00:00 AM | 8/19/2014 12:40 PM |
| Medicaid Billing | Medicaid: Number | Update | | FL-010060900 | 010060900 | 11/26/2013 4:55 PM |
| Dates | Participating Approval Date | Update | | | 11/26/2013 12:00:00 AM | 11/26/2013 4:55 PM |
| Details | State | Update | | Pending | Active | 11/26/2013 4:55 PM |
| Dates | Start Date | Update | | | 1/1/2014 12:00:00 AM | 11/26/2013 4:55 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG | PED103301-07 | 11/15/2013 4:10 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 10/10/2013 4:19 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | FL-010060900 | 10/10/2013 4:19 PM |
| Medicaid Billing | Medicaid: State | Insert | | | FL | 10/10/2013 4:19 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1871540237 | 10/10/2013 4:19 PM |
| Details | Last Recertification Date | Insert | | | | 10/10/2013 4:19 PM |
| Details | Grant Number | Insert | | | | 10/10/2013 4:19 PM |
| Details | 340B ID | Insert | | | OUTPATIENT_ONLINE_REG | 10/10/2013 4:19 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 10/10/2013 4:19 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 10/10/2013 4:19 PM |
| Details | Medicare Provider Number | Insert | | | 103301 | 10/10/2013 4:19 PM |
| Details | Entity Name | Insert | | | Miami Children's Hospital | 10/10/2013 4:19 PM |
| Details | Program Code | Insert | | | PED | 10/10/2013 4:19 PM |
| Details | Entity Subname | Insert | | | West Kendall Outpatient Center | 10/10/2013 4:19 PM |
| Dates | Participating Approval Date | Insert | | | | 10/10/2013 4:19 PM |
| Details | State | Insert | | | Pending | 10/10/2013 4:19 PM |
| Dates | Registration Date | Insert | | | 10/10/2013 12:00:00 AM | 10/10/2013 4:19 PM |
| Dates | Signed By Date | Insert | | | 10/10/2013 12:00:00 AM | 10/10/2013 4:19 PM |
| Dates | Start Date | Insert | | | | 10/10/2013 4:19 PM |
| Terminations | Termination Comments | Insert | | | | 10/10/2013 4:19 PM |
| Terminations | Termination Date | Insert | | | | 10/10/2013 4:19 PM |
| Terminations | Termination Effective Date | Insert | | | | 10/10/2013 4:19 PM |
| Terminations | Termination Reason | Insert | | | | 10/10/2013 4:19 PM |