Covered Entity Details

CHC26626-00 FOUNDCARE INC. (Active) - information as of 6/19/2025 11:51:39 PM

Main Details

Name

FOUNDCARE INC.

Subdivision Name

FoundCare Health Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-013288

340B ID

CHC26626-00

Grant Number

H80CS26626

Additional Details

Current Program Status

Active

Registration Date

1/8/2014

Participating Start Date

4/1/2014

Participating Approval Date

1/13/2014

Last Recertification Date

2/11/2025

Contacts

Authorizing Official

FoundCare, Inc.
Christopher Irizarry, CEO
(561) 472-9160 Ext: 207

Primary Contact

FoundCare, Inc.
Hyla Fritsch, Director of Pharmacy
(561) 472-9160 Ext: 343

Addresses

Street Address

2330 S. Congress Avenue
West Palm Beach, FL 33406-7608

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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	001182600,001182601,017383700,100397000,105801000,018523400,114016600,024731700,107712900,250128700,263957200,111680200,102535800,019927900,111811400,066864800,047441000,105605700,101762300,103914700,113386400,103906600,10726500,376590300,113664700,117424000,116038600,118974400,008353100,114459300,115570200,109768300,250010800,122736300,112762200,111713100,124254700,123710400,015800900,111731500,274327200	1215182712,1730670530,1235581315,1548758030,1891453072,1669914164,1598736555,1750342689,1083642243,1477227981,1194872317,1144766619,1275003139,1487683843,1093742686,1174985857,1851477343,1104488337,1457332488,1396105045,1669804720,1750391371,1083329759,1174164099,1679040778,1891201075,1043774367,1881393726,1518249317,1619057858,1821614819,1275627895,1861191124,1396580098,1679977896,1982442901,1467650101,1548270556,1699537654,1639540628,1225021694

Shipping Addresses

Shipping Address 1

FoundCare, Inc.
2330 S. Congress Avenue
West Palm Beach, FL 33406

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ATLANTIS PHARMACY RX LLC	100 JOHN F KENNEDY DR		ATLANTIS	FL	33462	07/12/2023	10/01/2023		10/01/2023
Contract Detail	BELLE GLADE DRUGS LLC	K & M DRUGS	624 S MAIN ST STE 1	BELLE GLADE	FL	33430	04/05/2024	07/01/2024		07/01/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	CND3, INC.	ROBALO PHARMACY	228 US HIGHWAY-1	LAKE PARK	FL	33403	10/29/2018	01/01/2019		01/01/2019
Contract Detail	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	01/15/2014	04/01/2014	06/30/2019	07/25/2019
Contract Detail	COMMCARE PHARMACY-WPB, LLC		1689 FORUM PLACE	WEST PALM BEACH	FL	33401	10/01/2014	01/01/2015	06/30/2019	07/25/2019
Contract Detail	ENCOMPASS RX, LLC	2700 NORTHEAST EXPRESSWAY	SUITE B-800	ATLANTA	GA	30345	07/18/2017	10/01/2017	06/30/2019	07/25/2019
Contract Detail	FOREST HILL PHARMACY LLC	2939 FOREST HILL BLVD		WEST PALM BEACH	FL	33406	10/14/2015	01/01/2016	11/20/2018	11/26/2018
Contract Detail	HEALTH FIRST INFUSION	1959 W 9TH ST STE A		RIVIERA BEACH	FL	33404-6440	01/14/2020	04/01/2020	06/25/2020	06/25/2020
Contract Detail	INFINITI PHARMACY AND INFUSION SERVICES	1338 NORTH FEDERAL HIGHWAY		POMPANO BEACH	FL	33062	01/15/2016	04/01/2016	01/15/2018	01/19/2018
Contract Detail	JTJ MEDICAL SUPPLY, INC	DBA MAIL MEDS CLINICAL PHARMACY	2692 OAK RIDGE CT	FORT MYERS	FL	33901	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	MAHANT RX INC	DBA BELLE GLADE PHARMACY	136 S MAIN ST STE B	BELLE GLADE	FL	33430-3424	01/15/2019	04/01/2019		04/01/2019
Contract Detail	MED-CARE INFUSION SERVICES	3085 W 80TH ST		HIALEAH	FL	33018-3888	04/09/2025	07/01/2025		04/09/2025
Contract Detail	PALMS HEALTH SERVICES LLC	PALMS PHARMACY	3491 S CONGRESS AVE	PALM SPRINGS	FL	33461-3021	04/07/2017	07/01/2017		04/07/2017
Contract Detail	PICC LINES PLUS, LLC	300 BUSINESS PARK WAY STE A1		ROYAL PALM BEACH	FL	33411-1756	04/07/2023	07/01/2023		07/01/2023
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/11/2017	07/01/2017	06/30/2019	07/25/2019
Contract Detail	PUBLIX PHARMACY #0371	CROSSTOWN PLAZA	2895 N MILITARY TRAIL	WEST PALM BEACH	FL	33409	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0055	1700 S CONGRESS AVENUE	PALM SPRINGS	FL	33461	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0050	828 SOUTHERN BLVD	WEST PALM BEACH	FL	33405	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0023	6790 FOREST HILL BLVD	GREENACRES	FL	33413	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0894	6820 OKEECHOBEE BLVD	WEST PALM BEACH	FL	33411	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS		PUBLIX PHARMACY #0319 831 VILLAGE BLVD	WEST PALM BEACH	FL	33409-1936	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS INC	DBA: PUBLIX PHAMRACY #0895	4849 SOUTH MILITARY TRAIL	GREENACRES	FL	33463	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS INC	PUBLIX PHARMACY #0817	1589 WEST LANTAN ROAD	LANTANA	FL	33462	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY # 1104	926 SOUTH MILITARY TRAIL	WEST PALM BEACH	FL	33415	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1384	214 NORTH DIXIE HIGHWAY	LAKE WORTH	FL	33460	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1395	135 BRADLEY PLACE	PALM BEACH	FL	33480	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	PUBLIX SUPERMARKETS		PUBLIX PHARMACY #0143 1910 LAKE WORTH ROAD	LAKE WORTH	FL	33461	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	RELIANCE PHARMACY LLC	GARDENS DRUGS	2100 45TH ST STE B1	WEST PALM BEACH	FL	33407-2063	01/15/2019	04/01/2019		04/01/2019
Contract Detail	SKYEMED PHARMACY & INFUSION SERVICE	SKYEMED PHARMACY & INFUSION SVCS	1332 NORTH FEDERAL HWY	POMPANO BEACH	FL	33062	01/14/2014	04/01/2014	01/15/2018	01/19/2018
Contract Detail	SKYEMED-PALM BEACH, INC	2330 S CONGRESS AVE, SUITE 237		WEST PALM BEACH	FL	33406-7608	02/09/2016	04/01/2016	01/15/2018	01/19/2018
Contract Detail	SUDDHA PHARMACY, LLC	FEDCO DRUGS	255 SUNRISE AVE	PALM BEACH	FL	33480	01/15/2016	04/01/2016		01/15/2016
Contract Detail	WAL-MART PHARMACY 10-1398	4545 HYPOLUXO RD		LAKE WORTH	FL	33463	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	WAL-MART PHARMACY 10-1436	6294 FOREST HILL BLVD		WEST PALM BEACH	FL	33415	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	WAL-MART PHARMACY 10-4560	6901 OKEECHOBEE BLVD		WEST PALM BEACH	FL	33411	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	WAL-MART PHARMACY 10-5301	4375 BELVEDERE RD		WEST PALM BEACH	FL	33406	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	WAL-MART PHARMACY 10-5758	3911 JOG RD		GREENACRES	FL	33467	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	WAL-MART PHARMACY 10-5759	6177 JOG ROAD		LAKE WORTH	FL	33467	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	WAL-MART PHARMACY 10-5882	2765 10TH AVE. NORTH		PALM SPRINGS	FL	33461	01/14/2014	04/01/2014	02/29/2016	03/01/2016
Contract Detail	WEST PALM PHARMACY	WEST PALM PHARMACY	5760 OKEECHOBEE BLVD	WEST PALM BEACH	FL	33417-3341	01/11/2024	04/01/2024		04/01/2024

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC26626-00	Active	BPS-H80-013288	FOUNDCARE INC.	FoundCare Health Center	2330 S. Congress Avenue	West Palm Beach	FL
CHC26626-01	Active	BPS-H80-017294	FOUNDCARE INC.	FoundCare - North Palm Beach	840 U.S. Highway 1 Ste 120	North Palm Beach	FL
CHC26626-02	Terminated	BPS-H80-021991	FoundCare Inc.	FoundCare Palm Beach Lakes High School Clinic	3505 Shiloh Drive	West Palm Beach	FL
CHC26626-03	Active	BPS-H80-024783	FoundCare Inc.	FoundCare West Palm Beach	5205 Greenwood Ave	West Palm Beach	FL
CHC26626-04	Active	BPS-H80-032290	FoundCare Inc.	FoundCare - Corporate Way	5730 Corporate Way Ste 100	West Palm Beach	FL
CHC26626-05	Active	BPS-H80-033500	FOUNDCARE INC.	FoundCare - Yolette Bonnet Center	5867 Okeechobee Blvd	West Palm Beach	FL
CHC26626-06	Active	BPS-H80-021255	FOUNDCARE INC.	FoundCare Belle Glade	1500 NW Avenue L	Belle Glade	FL
CHC26626-07	Active	BPS-H80-021256	FOUNDCARE INC.	FoundCare Boynton Beach	1901 S Congress Ave Ste 100	Boynton Beach	FL
CHC26626-08	Active	BPS-H80-036173	FOUNDCARE	FoundCare Mobile Unit	5205 Greenwood Avenue	West Palm Beach	FL
CHC26626-09	Approved	BPS-H80-039123	FOUNDCARE	FoundCare Dental Mobile Unit	2330 S Congress Ave	West Palm Beach	FL

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC26626-00	ATLANTIS PHARMACY RX LLC	100 JOHN F KENNEDY DR		ATLANTIS	FL	33462	10/01/2023
CHC26626-00	BELLE GLADE DRUGS LLC	K & M DRUGS	624 S MAIN ST STE 1	BELLE GLADE	FL	33430	07/01/2024
CHC26626-00	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/01/2017	06/30/2019
CHC26626-00	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/01/2017	06/30/2019
CHC26626-00	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/01/2017	06/30/2019
CHC26626-00	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/01/2017	06/30/2019
CHC26626-00	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/01/2017	06/30/2019
CHC26626-00	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/01/2017	06/30/2019
CHC26626-00	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/01/2017	06/30/2019
CHC26626-00	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/01/2017	06/30/2019
CHC26626-00	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/01/2017	06/30/2019
CHC26626-00	CND3, INC.	ROBALO PHARMACY	228 US HIGHWAY-1	LAKE PARK	FL	33403	01/01/2019
CHC26626-00	COMMCARE PHARMACY-FTL, LLC	855 SW 78TH AVE STE C100		PLANTATION	FL	33324-3223	04/01/2014	06/30/2019
CHC26626-00	COMMCARE PHARMACY-WPB, LLC		1689 FORUM PLACE	WEST PALM BEACH	FL	33401	01/01/2015	06/30/2019
CHC26626-00	ENCOMPASS RX, LLC	2700 NORTHEAST EXPRESSWAY	SUITE B-800	ATLANTA	GA	30345	10/01/2017	06/30/2019
CHC26626-00	FOREST HILL PHARMACY LLC	2939 FOREST HILL BLVD		WEST PALM BEACH	FL	33406	01/01/2016	11/20/2018
CHC26626-00	HEALTH FIRST INFUSION	1959 W 9TH ST STE A		RIVIERA BEACH	FL	33404-6440	04/01/2020	06/25/2020
CHC26626-00	INFINITI PHARMACY AND INFUSION SERVICES	1338 NORTH FEDERAL HIGHWAY		POMPANO BEACH	FL	33062	04/01/2016	01/15/2018
CHC26626-00	JTJ MEDICAL SUPPLY, INC	DBA MAIL MEDS CLINICAL PHARMACY	2692 OAK RIDGE CT	FORT MYERS	FL	33901	04/01/2014	02/29/2016
CHC26626-00	MAHANT RX INC	DBA BELLE GLADE PHARMACY	136 S MAIN ST STE B	BELLE GLADE	FL	33430-3424	04/01/2019
CHC26626-00	MED-CARE INFUSION SERVICES	3085 W 80TH ST		HIALEAH	FL	33018-3888	07/01/2025
CHC26626-00	PALMS HEALTH SERVICES LLC	PALMS PHARMACY	3491 S CONGRESS AVE	PALM SPRINGS	FL	33461-3021	07/01/2017
CHC26626-00	PICC LINES PLUS, LLC	300 BUSINESS PARK WAY STE A1		ROYAL PALM BEACH	FL	33411-1756	07/01/2023
CHC26626-00	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/01/2017	06/30/2019
CHC26626-00	PUBLIX PHARMACY #0371	CROSSTOWN PLAZA	2895 N MILITARY TRAIL	WEST PALM BEACH	FL	33409	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0055	1700 S CONGRESS AVENUE	PALM SPRINGS	FL	33461	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0050	828 SOUTHERN BLVD	WEST PALM BEACH	FL	33405	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0023	6790 FOREST HILL BLVD	GREENACRES	FL	33413	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS	PUBLIX PHARMACY #0894	6820 OKEECHOBEE BLVD	WEST PALM BEACH	FL	33411	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS		PUBLIX PHARMACY #0319 831 VILLAGE BLVD	WEST PALM BEACH	FL	33409-1936	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS INC	DBA: PUBLIX PHAMRACY #0895	4849 SOUTH MILITARY TRAIL	GREENACRES	FL	33463	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS INC	PUBLIX PHARMACY #0817	1589 WEST LANTAN ROAD	LANTANA	FL	33462	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY # 1104	926 SOUTH MILITARY TRAIL	WEST PALM BEACH	FL	33415	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1384	214 NORTH DIXIE HIGHWAY	LAKE WORTH	FL	33460	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPER MARKETS, INC.	PUBLIX PHARMACY #1395	135 BRADLEY PLACE	PALM BEACH	FL	33480	04/01/2014	02/29/2016
CHC26626-00	PUBLIX SUPERMARKETS		PUBLIX PHARMACY #0143 1910 LAKE WORTH ROAD	LAKE WORTH	FL	33461	04/01/2014	02/29/2016
CHC26626-00	RELIANCE PHARMACY LLC	GARDENS DRUGS	2100 45TH ST STE B1	WEST PALM BEACH	FL	33407-2063	04/01/2019
CHC26626-00	SKYEMED PHARMACY & INFUSION SERVICE	SKYEMED PHARMACY & INFUSION SVCS	1332 NORTH FEDERAL HWY	POMPANO BEACH	FL	33062	04/01/2014	01/15/2018
CHC26626-00	SKYEMED-PALM BEACH, INC	2330 S CONGRESS AVE, SUITE 237		WEST PALM BEACH	FL	33406-7608	04/01/2016	01/15/2018
CHC26626-01	SKYEMED-PALM BEACH, INC	2330 S CONGRESS AVE, SUITE 237		WEST PALM BEACH	FL	33406-7608	04/01/2016	10/31/2018
CHC26626-00	SUDDHA PHARMACY, LLC	FEDCO DRUGS	255 SUNRISE AVE	PALM BEACH	FL	33480	04/01/2016
CHC26626-00	WAL-MART PHARMACY 10-1398	4545 HYPOLUXO RD		LAKE WORTH	FL	33463	04/01/2014	02/29/2016
CHC26626-00	WAL-MART PHARMACY 10-1436	6294 FOREST HILL BLVD		WEST PALM BEACH	FL	33415	04/01/2014	02/29/2016
CHC26626-00	WAL-MART PHARMACY 10-4560	6901 OKEECHOBEE BLVD		WEST PALM BEACH	FL	33411	04/01/2014	02/29/2016
CHC26626-00	WAL-MART PHARMACY 10-5301	4375 BELVEDERE RD		WEST PALM BEACH	FL	33406	04/01/2014	02/29/2016
CHC26626-00	WAL-MART PHARMACY 10-5758	3911 JOG RD		GREENACRES	FL	33467	04/01/2014	02/29/2016
CHC26626-00	WAL-MART PHARMACY 10-5759	6177 JOG ROAD		LAKE WORTH	FL	33467	04/01/2014	02/29/2016
CHC26626-00	WAL-MART PHARMACY 10-5882	2765 10TH AVE. NORTH		PALM SPRINGS	FL	33461	04/01/2014	02/29/2016
CHC26626-00	WEST PALM PHARMACY	WEST PALM PHARMACY	5760 OKEECHOBEE BLVD	WEST PALM BEACH	FL	33417-3341	04/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	109337400 (FL)		4/9/2025 4:53 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1275061426 (FL)		4/9/2025 4:53 PM
Details	Last Recertification Date	Update	Recertification	2/1/2024 1:12:57 PM	2/11/2025 9:38:46 AM	2/11/2025 9:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	1/8/2025 4:46 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		111731500	1/8/2025 4:46 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	1/8/2025 4:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	1/8/2025 4:46 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		274327200	1/8/2025 4:46 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	1/8/2025 4:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1639540628	1/8/2025 4:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	1/8/2025 4:46 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1225021694	1/8/2025 4:46 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	1/8/2025 4:46 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		124254700	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		123710400	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		015800900	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	11/18/2024 10:13 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1548270556	11/18/2024 10:13 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	11/18/2024 10:13 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1699537654	11/18/2024 10:13 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	11/18/2024 10:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/28/2024 10:05 AM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		111713100	10/28/2024 10:05 AM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	10/28/2024 10:05 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1467650101	10/28/2024 10:05 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	10/28/2024 10:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/23/2024 2:42 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		109337400	9/23/2024 2:42 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	9/23/2024 2:42 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1275061426	9/23/2024 2:42 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	9/23/2024 2:42 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1982442901	9/23/2024 2:42 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	9/23/2024 2:42 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	8/15/2024 12:07 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		112762200	8/15/2024 12:07 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	8/15/2024 12:07 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1679977896	8/15/2024 12:07 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	8/15/2024 12:07 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1396580098	7/18/2024 12:02 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	7/18/2024 12:02 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	105557600 (FL)		7/10/2024 5:26 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	115155500 (FL)		7/10/2024 5:26 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	104906900 (FL)		7/10/2024 5:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/10/2024 5:26 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		250010800	7/10/2024 5:26 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	7/10/2024 5:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	7/10/2024 5:26 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		122736300	7/10/2024 5:26 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	7/10/2024 5:26 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1104011774 (FL)		7/10/2024 5:26 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1083293757 (FL)		7/10/2024 5:26 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1679544704 (FL)		7/10/2024 5:26 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1275627895	7/10/2024 5:26 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	7/10/2024 5:26 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861191124	7/10/2024 5:26 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	7/10/2024 5:26 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	117140000 (FL)		6/6/2024 3:05 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	6/6/2024 3:05 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		109768300	6/6/2024 3:05 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	6/6/2024 3:05 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1982030276 (FL)		6/6/2024 3:05 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1821614819	6/6/2024 3:05 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	6/6/2024 3:05 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	111363400 (FL)		5/29/2024 5:03 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	111713100 (FL)		5/29/2024 5:03 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	023885800 (FL)		5/29/2024 5:03 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	109768300 (FL)		5/29/2024 5:03 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	105219900 (FL)		5/29/2024 5:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/29/2024 5:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		104906900	5/29/2024 5:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	5/29/2024 5:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/29/2024 5:03 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		117140000	5/29/2024 5:03 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	5/29/2024 5:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1467650101 (FL)		5/29/2024 5:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1740363589 (FL)		5/29/2024 5:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1821614819 (FL)		5/29/2024 5:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1992863740 (FL)		5/29/2024 5:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265086805 (FL)		5/29/2024 5:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1679544704	5/29/2024 5:03 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	5/29/2024 5:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1982030276	5/29/2024 5:03 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	5/29/2024 5:03 PM
Details	Last Recertification Date	Update	Recertification	1/31/2023 9:12:33 AM	2/1/2024 1:12:57 PM	2/1/2024 1:12 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	015668500 (FL)		1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		118974400	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		008353100	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		114459300	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		115570200	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	1/11/2024 3:00 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1841554797 (FL)		1/11/2024 3:00 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1881393726	1/11/2024 3:00 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	1/11/2024 3:00 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1518249317	1/11/2024 3:00 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	1/11/2024 3:00 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1619057858	1/11/2024 3:00 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	1/11/2024 3:00 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	023286900 (FL)		10/18/2023 10:42 AM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1447466313 (FL)		10/18/2023 10:42 AM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	118786700 (FL)		10/2/2023 3:24 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	10/2/2023 3:24 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		115155500	10/2/2023 3:24 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	10/2/2023 3:24 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1457864803 (FL)		10/2/2023 3:24 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1083293757	10/2/2023 3:24 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	10/2/2023 3:24 PM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1043774367	10/2/2023 3:24 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	10/2/2023 3:24 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	117153200 (FL)		9/8/2023 3:07 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	025105200 (FL)		9/8/2023 3:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Group Change Request		False	9/8/2023 3:07 PM
Medicaid Billing	Medicaid: Number	Insert	Group Change Request		118786700	9/8/2023 3:07 PM
Medicaid Billing	Medicaid: State	Insert	Group Change Request		FL	9/8/2023 3:07 PM
Medicaid Billing	NPI: Number	Delete	Group Change Request	1295170256 (FL)		9/8/2023 3:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		117424000	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		116038600	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		105219900	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	5/23/2023 3:31 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265086805	5/23/2023 3:31 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	5/23/2023 3:31 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1891201075 (FL)		4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	011433900 (FL)		4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	108824600 (FL)		4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		113664700	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		117153200	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		025105200	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1104203355 (FL)		4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1659814812 (FL)		4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1134864317 (FL)		4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1134646482 (FL)		4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1083329759	4/14/2023 2:50 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1174164099	4/14/2023 2:50 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1295170256	4/14/2023 2:50 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1457864803	4/14/2023 2:50 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1679040778	4/14/2023 2:50 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1891201075	4/14/2023 2:50 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	4/14/2023 2:50 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		001182600	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		001182601	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		017383700	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100397000	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		105557600	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		105801000	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		018523400	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1891201075	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		111363400	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		114016600	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		024731700	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		107712900	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		250128700	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		263957200	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		111680200	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		102535800	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		019927900	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		011433900	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		111713100	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		111811400	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		066864800	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		023286900	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		047441000	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		105605700	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		023885800	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		108824600	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		101762300	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		103914700	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		109768300	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		113386400	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		103906600	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10726500	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		015668500	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		376590300	2/3/2023 9:04 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1215182712	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1730670530	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1104011774	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1235581315	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1104203355	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1548758030	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1891453072	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1669914164	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1598736555	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1750342689	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1083642243	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1477227981	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194872317	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1144766619	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1659814812	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1467650101	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1275003139	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1487683843	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1447466313	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1093742686	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1134864317	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1174985857	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1740363589	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1134646482	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1851477343	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1104488337	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1821614819	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1992863740	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457332488	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1396105045	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1669804720	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1841554797	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1750391371	2/3/2023 9:04 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	2/3/2023 9:04 AM
Contacts	Authorizing Official	Update	Group Change Request	Pavlescak, Rik Chief Administrative Officer FoundCare, Inc. 5614327902	Irizarry, Christopher CEO FoundCare, Inc. 5614729160-207	2/2/2023 9:24 AM
Details	Last Recertification Date	Update	Recertification	1/31/2022 10:53:28 AM	1/31/2023 9:12:33 AM	1/31/2023 9:12 AM
Contacts	Primary Contact	Update	Group Change Request	Neff, James Director of Pharmacy FoundCare, Inc. 5614729160-343	Fritsch, Hyla Director of Pharmacy FoundCare, Inc. 5614729160-343	1/19/2023 8:05 AM
Details	Last Recertification Date	Update	Recertification	2/8/2021 9:48:04 AM	1/31/2022 10:53:28 AM	1/31/2022 10:53 AM
Contacts	Authorizing Official	Update	Profile Change Request	Pavlescak, Rik Deputy Chief Executive Officer FoundCare, Inc. 5614327902	Pavlescak, Rik Chief Administrative Officer FoundCare, Inc. 5614327902	1/3/2022 11:09 AM
Contacts	Signed By	Update	Profile Change Request	Pavlescak, Rik Deputy Chief Executive Officer FoundCare, Inc. 5614327902	Pavlescak, Rik Chief Administrative Officer FoundCare, Inc. 5614327902	1/3/2022 11:09 AM
Contacts	Authorizing Official	Update	Profile Change Request	Pavlescak, Rik Chief Operating Officer FoundCare, Inc. 5614327902	Pavlescak, Rik Deputy Chief Executive Officer FoundCare, Inc. 5614327902	4/15/2021 2:09 PM
Contacts	Signed By	Update	Profile Change Request	Pavlescak, Rik Chief Operating Officer FoundCare, Inc. 5614327902	Pavlescak, Rik Deputy Chief Executive Officer FoundCare, Inc. 5614327902	4/15/2021 2:09 PM
Contacts	Primary Contact	Update	Recertification	Prol, Elizabeth Director of Health Center Operations FoundCare, Inc. 5614729160-114	Neff, James Director of Pharmacy FoundCare, Inc. 5614729160-343	2/8/2021 9:48 AM
Details	Last Recertification Date	Update	Recertification	2/4/2020 8:53:57 AM	2/8/2021 9:48:04 AM	2/8/2021 9:48 AM
Details	Last Recertification Date	Update	Recertification	1/29/2019 11:29:09 AM	2/4/2020 8:53:57 AM	2/4/2020 8:53 AM
Addresses	Shipping Address	Insert	Change Request		FoundCare, Inc. 2330 S. Congress Avenue West Palm Beach, FL 33406	5/20/2019 7:30 AM
Addresses	Main Address	Update	Change Request	2330 S Congress Ave West Palm Beach, FL 33406-7608	2330 S. Congress Avenue West Palm Beach, FL 33406-7608	5/20/2019 7:30 AM
Details	Last Recertification Date	Update	Recertification	2/7/2018 2:02:19 PM	1/29/2019 11:29:09 AM	1/29/2019 11:29 AM
Contacts	Primary Contact	Update	Recertification	Pavlescak, Rik Chief Operating Officer FoundCare, Inc. 5614327902	Prol, Elizabeth Director of Health Center Operations FoundCare, Inc. 5614729160-114	2/7/2018 2:02 PM
Details	Last Recertification Date	Update	Recertification	2/1/2017 12:00:00 AM	2/7/2018 2:02:19 PM	2/7/2018 2:02 PM
Details	Is Authorizing Official EHB Data	Update	Recertification	False		2/7/2018 2:02 PM
Contacts	Authorizing Official	Update		Pavlescak, Rik Chief Operating Officer 5614327902	Pavlescak, Rik Chief Operating Officer FoundCare, Inc. 5614327902	10/2/2017 11:43 AM
Contacts	Primary Contact	Update		Pavlescak, Rik Chief Operating Officer 5614327902	Pavlescak, Rik Chief Operating Officer FoundCare, Inc. 5614327902	10/2/2017 11:43 AM
Contacts	Signed By	Update		Pavlescak, Rik Chief Operating Officer 5614327902	Pavlescak, Rik Chief Operating Officer FoundCare, Inc. 5614327902	10/2/2017 11:43 AM
Contacts	Authorizing Official	Insert			Pavlescak, Rik Chief Operating Officer 5614327902	7/18/2017 10:13 AM
Contacts	Primary Contact	Insert			Pavlescak, Rik Chief Operating Officer 5614327902	7/18/2017 10:13 AM
Contacts	Signed By	Insert			Pavlescak, Rik Chief Operating Officer 5614327902	7/18/2017 10:13 AM
Addresses	Main Address	Insert			2330 S Congress Ave West Palm Beach, FL 33406-7608	2/1/2017 10:34 AM
Details	Last Recertification Date	Update		2/25/2016 12:00:00 AM	2/1/2017 12:00:00 AM	2/1/2017 10:33 AM
Details	Last Recertification Date	Update		2/10/2015 12:00:00 AM	2/25/2016 12:00:00 AM	2/25/2016 1:37 PM
Details	Last Recertification Date	Update			2/10/2015 12:00:00 AM	2/10/2015 3:03 PM
Details	Is Authorizing Official EHB Data	Update			False	2/10/2015 3:03 PM
Details	340B ID	Update		ONLINE_REG	CHC26626-00	1/13/2014 12:49 PM
Dates	Participating Approval Date	Update			1/13/2014 12:00:00 AM	1/13/2014 12:49 PM
Details	State	Update		Pending	Active	1/13/2014 12:49 PM
Dates	Start Date	Update			4/1/2014 12:00:00 AM	1/13/2014 12:49 PM
Details	Last Recertification Date	Insert				1/8/2014 1:43 PM
Details	Grant Number	Insert			H80CS26626	1/8/2014 1:43 PM
Details	340B ID	Insert			ONLINE_REG	1/8/2014 1:43 PM
Details	Is Authorizing Official EHB Data	Insert				1/8/2014 1:43 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/8/2014 1:43 PM
Details	Medicare Provider Number	Insert				1/8/2014 1:43 PM
Details	Entity Name	Insert			FOUNDCARE INC.	1/8/2014 1:43 PM
Details	Program Code	Insert			CH	1/8/2014 1:43 PM
Details	Entity Subname	Insert			FoundCare Health Center	1/8/2014 1:43 PM
Dates	Participating Approval Date	Insert				1/8/2014 1:43 PM
Details	State	Insert			Pending	1/8/2014 1:43 PM
Dates	Registration Date	Insert			1/8/2014 12:00:00 AM	1/8/2014 1:43 PM
Dates	Signed By Date	Insert			1/8/2014 12:00:00 AM	1/8/2014 1:43 PM
Dates	Start Date	Insert				1/8/2014 1:43 PM
Terminations	Termination Comments	Insert				1/8/2014 1:43 PM
Terminations	Termination Date	Insert				1/8/2014 1:43 PM
Terminations	Termination Effective Date	Insert				1/8/2014 1:43 PM
Terminations	Termination Reason	Insert				1/8/2014 1:43 PM

340B Drug Pricing Program Database