340B Drug Pricing Program Database


CH04170M COLLIER HEALTH SERVICES, INC. (Active) - information as of 5/30/2025 8:18:26 PM

Main Details
COLLIER HEALTH SERVICES, INC.
Nichols Community Health Center
HRSA-Funded Health Center
BPS-H80-030431
CH04170M
H80CS00735


Additional Details
Active
7/1/2015
10/1/2015
7/6/2015
2/18/2025

Contacts

Collier Health Services, Inc., d/b/a Healthcare Network
John Fletcher, Chief Operating Officer & General Counsel
(239) 658-3060

Collier Health Services, Inc.
Martine Woolley, Vice President of Pharmacy
(239) 658-3030

Addresses

12655 Collier Blvd
NAPLES, FL 34116-7591

Collier Health Services, Inc., d/b/a Healthcare Network
1454 Madison Ave W
Immokalee, FL 34142


  • Comments
  • Medicaid Billing
  • Shipping Addresses
  • Contract Pharmacies
  • Grantee Sites
  • Grantee Sites Contract Pharmacies
  • History
Comments
CommentLast Updated On 
No records to display.
Medicaid Billing

Yes
StateMedicaid NumberNPI Number
FL029152814,029152815,019612100,029152803,061426201,683955012,683955013,683955005,253277806,029152805,253277803,683955024,683955025,029152810,029152811,683955017,683955018,683955023,683955026,683955010,683955011,102892800,683955006,029152818,029152819,029152820,029152821,029152822,029152823,029152826,029152827,683955007,683955030,029152824,029152825,029152828,029152829,029152832,0291528331679124010,1962951996,1134331416,1053526962,1194919993,1376738690,1477229755,1407061310,1316152226,1851505200,1134334048,1689031049,1497112858,1508079245,1588879498,1659864411,1528564911,1467829424,1154799138,1841484516,1073707741,1184707689,1588026397,1396107108,1861607772,1770798688,1871366427,1891551610,1255107629,1164276291,1447099106,1255170916,1942059910,1932958907,1790502615,1417774332,1902621477,1639994106,1235946716,1780491258,1538976006,1083421556,1336959980
Shipping Addresses

Collier Health Services, Inc., d/b/a Healthcare Network
12655 Collier Blvd
Naples, FL 34116

Collier Health Services, Inc., Healthcare Network of Southwest Florida
12655 Collier Blvd
Naples, FL 34116
Grantee Sites
340B ID 340B StatusSiteIdNameSub NameAddressAddress Cont.CityState
CH041700ActiveAdminCOLLIER HEALTH SERVICES, INC.COLLIER HEALTH SERVICES, INC.1454 Madison Ave W ImmokaleeFL
CH04170ATerminatedBPS-H80-030431COLLIER HEALTH SERVICES, INC.Nichols Community Health Center12655 Collier Blvd NaplesFL
CH04170AAActiveBPS-H80-038148COLLIER HEALTH SERVICES INCHealthcare Network Cordero Pediatrics1090 6th Ave N NaplesFL
CH04170ABActiveBPS-H80-038514COLLIER HEALTH SERVICES INCHealthcare Network North (Veterans Park)1845 Veterans Park Dr NaplesFL
CH04170ACActiveBPS-H80-038624COLLIER HEALTH SERVICES INCHealthcare Network - Mobile Outreach 11454 Madison Ave W ImmokaleeFL
CH04170ADActiveBPS-H80-039042COLLIER HEALTH SERVICES INCHealthcare Network Manatee Middle1920 Manatee Rd NaplesFL
CH04170AEActiveBPS-H80-039161COLLIER HEALTH SERVICES INCHealthcare Network Badra Pediatrics9160 Galleria Ct NaplesFL
CH04170AFActiveBPS-H80-039566COLLIER HEALTH SERVICES INCHealthcare Network Community Medical Care Center125 Boston Ave ImmokaleeFL
CH04170AGActiveBPS-H80-039565COLLIER HEALTH SERVICES INCHealthcare Network Mobile Outreach 21454 Madison Ave W UNIT 4 ImmokaleeFL
CH04170AHActiveBPS-H80-039567COLLIER HEALTH SERVICES INCHealthcare Network Van Domelen Health Express1454 Madison Ave W UNIT 3 ImmokaleeFL
CH04170AJApprovedBPS-H80-039772COLLIER HEALTH SERVICES INCHealthcare Network Ekos Allegro8455 Rattlesnake Hammock Rd STE CH-105 NaplesFL
CH04170BTerminatedBPS-H80-015084COLLIER HEALTH SERVICES, INC.Total Women&s Care of Naples1890 SW Health Parkway, Suite 203 NaplesFL
CH04170CActiveBPS-H80-013952COLLIER HEALTH SERVICES, INC.Children's Care East6350 DAVIS BLVD NAPLESFL
CH04170DTerminatedBPS-H80-010730COLLIER HEALTH SERVICES, INC.Creekside Family Practice1284 Creekside St NaplesFL
CH04170EActiveBPS-H80-010214COLLIER HEALTH SERVICES, INC.CREEKSIDE PEDIATRICS1265 Creekside Pkwy STE 208 NaplesFL
CH04170FActiveBPS-H80-009167COLLIER HEALTH SERVICES, INC.Immokalee Family Care Center508 N 9th St ImmokaleeFL
CH04170GActiveBPS-H80-007372COLLIER HEALTH SERVICES, INC.RONALD MCDONALD CARE MOBILE1454 Madison Ave W ImmokaleeFL
CH04170HTerminatedBPS-H80-005572COLLIER HEALTH SERVICES, INC.The Mike Davis Medical Center1755 HERITAGE TRAIL NAPLESFL
CH04170JActiveBPS-H80-004275COLLIER HEALTH SERVICES, INC.CHS-FSU Primary Care1441 HERITAGE BLVD IMMOKALEEFL
CH04170KTerminatedBPS-H80-003592COLLIER HEALTH SERVICES, INC.CENTRAL NAPLES PEDIATRICS3425 10th St N NaplesFL
CH04170LActiveBPS-H80-002996COLLIER HEALTH SERVICES, INC.Countryside Dental1749 Heritage Trail NaplesFL
CH04170MActiveBPS-H80-030431COLLIER HEALTH SERVICES, INC.Nichols Community Health Center12655 Collier Blvd NAPLESFL
CH04170NTerminatedBPS-H80-030431COLLIER HEALTH SERVICES, INC.GOLDEN GATE PEDIATRICS12655 Collier Blvd NaplesFL
CH04170PTerminatedBPS-H80-001174COLLIER HEALTH SERVICES, INC.MARCO ISLAND PEDIATRICS40 HEATHWOOD DRIVE STE F MARCO ISLANDFL
CH04170QActiveBPS-H80-017394COLLIER HEALTH SERVICES, INC.Health and Smiles1454 Madison Ave W ImmokaleeFL
CH04170RActiveBPS-H80-015787COLLIER HEALTH SERVICES, INC.Friendship Health Center2355 Stanford Court NaplesFL
CH04170STerminatedBPS-H80-007640COLLIER HEALTH SERVICES, INC.CHS University of Florida Pediatric Dental Center7505 Grand Lely Drive NaplesFL
CH04170TActiveBPS-H80-005514COLLIER HEALTH SERVICES, INC.MARION E FETHER MEDICAL CENTER1454 Madison Ave W ImmokaleeFL
CH04170UTerminatedBPS-H80-017396COLLIER HEALTH SERVICES, INC.Dental Care Central4077 Tamiami Trail North NaplesFL
CH04170VActiveBPS-H80-017201COLLIER HEALTH SERVICES, INC.Nichols Pediatric Center5450 YMCA Road NaplesFL
CH04170WTerminatedBPS-H80-019083COLLIER HEALTH SERVICES, INC.Family Care DLC6075 Bathey Ln. NaplesFL
CH04170XActiveBPS-H80-021572COLLIER HEALTH SERVICES, INC.Family Care North1265 Creekside Pkwy Ste 206 NaplesFL
CH04170YTerminatedBPS-H80-022240COLLIER HEALTH SERVICES, INC.Children's Care West1008 Goodlette-Frank Rd STE 100 NaplesFL
CH04170ZTerminatedBPS-H80-037037COLLIER HEALTH SERVICES INCHealthcare Network Apple Pediatrics7795 Davis Blvd, Ste 206 NaplesFL
Grantee Sites Contract Pharmacies
340B IDPharmacy NameAddressAddress Cont.CityStateZip CodeBegin DateCarve-In Effective DateTermination Date
CH041700AMERICAN DISCOUNT PHARMACY CORP.  110 E. MAIN STREET
SUITE A
IMMOKALEEFL34142-339504/01/2015 11/17/2015
CH041700CAREMARK FLORIDA SPECIALTY PHARMACY LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7930 WOODLAND CENTER BLVD STE 500
TAMPAFL3361401/01/2022  
CH041700CAREMARK ILLINOIS SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 800 BIERMANN CT STE B
MOUNT PROSPECTIL6005601/01/2022  
CH041700CAREMARK KANSAS SPECIALTY PHARMACYCVS/SPECIALTY OR CARELONRX SPECIALTY PHA 11162 RENNER BLVD
LENEXAKS6621901/01/2022  
CH041700CAREMARK MASSACHUSETTS SPECIALTY PHARMACDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 25 BIRCH STREET, BLDG B, SUITE 100
MILFORDMA0175701/01/2022  
CH041700CAREMARK MICHIGAN SPECIALTY PHARMACY, LLDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1307 ALLEN DR STE H
TROYMI4808301/01/2022  
CH041700CAREMARK NEW JERSEY SPECIALTY PHCY, LLCDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 180 PASSAIC AVE UNIT B-5
FAIRFIELDNJ0700401/01/2022  
CH041700CAREMARK NORTH CAROLINA SPECIALTY PHARMADBA CVS/SPECIALTY OR CARELONRX SPECIALTY 10700 WORLD TRADE BLVD STE 110
RALEIGHNC2761701/01/2022  
CH041700CAREMARK TENNESSEE SPECIALTY PHARMACY, LDBA CVS/SPECIALTY OR CARELONRX SPECIALTY 8370 WOLF LAKE DR
STE 107
BARTLETTTN3813301/01/2022  
CH041700CAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 1127 BRYN MAWR AVE
SUITE A
REDLANDSCA9237401/01/2022  
CH041700CAREMARK, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 7251 S. EASTERN AVE.
LAS VEGASNV8911901/01/2022  
CH041700CVS/SPECIALTY OR CARELONRX SPECIALTY PHACAREMARK, LLC 1001 SPINKS ROAD, STE 280
FLOWER MOUNDTX7502801/01/2022  
CH041700CYSTIC FIBROSIS SERVICES, LLCDBA WALGREENS SPECIALTY PHARMACY #16280 10530 JOHN W ELLIOTT DR STE 200
FRISCOTX7503304/01/2024  
CH041700GENOA HEALTHCARE LLC6075 BATHEY LANE, SUITE D-5
NAPLESFL3411610/01/2017 01/15/2022
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03248 1102 N 15TH ST
IMMOKALEEFL3414204/01/2016  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05041 5585 GOLDEN GATE PKWY
NAPLESFL3411610/01/2017  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 08927 8831 IMMOKALEE RD.
NAPLESFL3412010/01/2017  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 01807 1350 LEE BLVD
LEHIGH ACRESFL3393601/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 01816 5296 TAMIAMI TRL N
NAPLESFL3410301/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03266 4890 TAMIAMI TR
NAPLESFL3411201/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03677 2344 IMMOKALEE RD
NAPLESFL3411001/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 04228 5070 AIRPORT RD N
NAPLESFL3410501/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA CVS/PHARMACY #4738 13400 IMMOKALEE ROAD
NAPLESFL3412001/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05187 2375 VANDERBILT BEACH RD
NAPLESFL3410901/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05375 14240 TAMIAMI TRAIL NORTH
NAPLESFL3411001/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05787 11500 BONITA BEACH RD. SE
BONITA SPRINGSFL3413501/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05824 2515 SHADOWLAWN DR.
NAPLESFL3411201/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 07899 6800 COLLIER BLVD,
NAPLESFL3411401/01/2022  
CH041700HOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 08397 7380 DAVIS BLVD
NAPLESFL3410401/01/2022  
CH041700HOLIDAY CVS, L.L.C.CVS PHARMACY # 17433 9350 DYNASTY DR
FT MYERSFL3390501/01/2022  
CH04170JHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03248 1102 N 15TH ST
IMMOKALEEFL3414201/01/2024  
CH04170VHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 05041 5585 GOLDEN GATE PKWY
NAPLESFL3411601/01/2024  
CH04170RHOLIDAY CVS, L.L.C.DBA CVS/PHARMACY #4738 13400 IMMOKALEE ROAD
NAPLESFL3412001/01/2024  
CH04170GHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03266 4890 TAMIAMI TR
NAPLESFL3411201/01/2024 10/11/2023
CH04170GHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 01807 1350 LEE BLVD
LEHIGH ACRESFL3393601/01/2024  
CH04170CHOLIDAY CVS, L.L.C.DBA: CVS/PHARMACY # 03266 4890 TAMIAMI TR
NAPLESFL3411201/01/2024  
CH041700JTJ MEDICAL SUPPLY, INCDBA MAIL MEDS CLINICAL PHARMACY 2692 OAK RIDGE CT
FORT MYERSFL3390110/01/2015  
CH041700PROCARE PHARMACY DIRECT, L.L.C.DBA CVS/SPECIALTY OR CARELONRX SPECIALTY 105 MALL BOULEVARD
MONROEVILLEPA1514601/01/2022  
CH041700PROCARE PHARMACY, L.L.C.DBA: CVS/PHARMACY #2909 1521 4TH AVE., SOUTH
BIRMINGHAMAL3523301/01/2022  
CH041700PROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY OR CARELONRX SPECIALTY ONE WATERFRONT PLAZA
500 ALA MOANA BLVD., BLDG 1
HONOLULUHI9681301/01/2022  
CH041700PROCARE PHARMACY, L.L.C.DBA CVS/PHARMACY #2923 3250 HARDEN ST. EXT. SUITE #300
COLUMBIASC2920301/01/2022  
CH041700SIDDH INCTOWN PHARMACY 107 W MAIN ST
IMMOKALEEFL34142-341410/01/2015 02/09/2017
CH041700US SPECIALTY CARE PHARMACY  7472 S TUCSON WAY
SUITE 100-B
CENTENNIALCO80112-445204/01/2015 02/01/2016
CH041700WAL-MART CENTRAL FILL 10-2670608 SPRING HILL DR # 3 SUITE 300
SPRINGTX7738601/01/2023  
CH041700WAL-MART PHARMACY 10-11193451 TAMIAMI TRAIL EAST
NAPLESFL3411204/01/2016  
CH041700WAL-MART PHARMACY 10-195711225 TAMIAMI TRAIL NORTH
NAPLESFL3411004/01/2016  
CH041700WAL-MART PHARMACY 10-22372523 LEE BLVD
LEHIGH ACRESFL3397104/01/2016  
CH041700WAL-MART PHARMACY 10-34176650 COLLIER BOULEVARD
NAPLESFL3411404/01/2016  
CH041700WAL-MART PHARMACY 10-43545010 AIRPORT PULLING ROAD
NAPLESFL3410504/01/2016  
CH041700WAL-MART PHARMACY 10-50559885 COLLIER BLVD
NAPLES (SE)FL3411404/01/2016  
CH041700WAL-MART PHARMACY 10-53915420 JULIET BOULEVARD
NAPLESFL3410904/01/2016  
CH041700WAL-MART PHARMACY 10-59979600 PARKSOUTH CT. SUITE 100
ORLANDOFL3283701/01/2023  
CH041700WALGREEN CODBA: WALGREENS #10794 12955 COLLIER BLVD
NAPLESFL3411604/01/2017 07/01/2017
CH041700WALGREEN CO.DBA: WALGREENS # 05693 1450 IMMOKALEE DRIVE
IMMOKALEEFL3414207/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS # 04482 1565 AIRPORT ROAD SOUTH
NAPLESFL3410410/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS # 04524 12780 TAMIAMI TRAIL E
NAPLESFL3411310/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS # 05197 1800 SAN MARCO RD
MARCO ISLANDFL3414510/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS # 05330 1100 N. COLLIER BLVD.
MARCO ISLANDFL3414510/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS # 06071 38 HOMESTEAD RD N
LEHIGH ACRESFL33936-664610/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS # 06500 4290 TAMIAMI TRAILS EAST
NAPLESFL3411210/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS # 06775 15295 COLLIER BLVD
NAPLESFL34119-771510/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS # 10204 2200 TAMIAMI TRL N
NAPLESFL3410310/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS #10742 30 GOLDEN GATE BLVD W
NAPLESFL3412010/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS #11658 4747 GOLDEN GATE PKWY
NAPLESFL3411610/01/2015  
CH041700WALGREEN CO.DBA: WALGREENS #04958 7985 AIRPORT RD N
NAPLESFL3410904/01/2017  
CH041700WALGREEN CO.DBA: WALGREENS #16052 2511 PINE RIDGE RD
NAPLESFL3410904/01/2018  
CH041700WALGREEN CO.DBA: WALGREENS # 02542 7301 RADIO ROAD
NAPLESFL3410404/01/2018  
CH041700WALGREEN CO.DBA: WALGREENS # 04167 8900 TAMIAMI TRAIL NORTH
NAPLESFL3410807/01/2018  
CH041700WALGREEN CO.DBA: WALGREENS # 02895 6029 PINE RIDGE ROAD
NAPLESFL3411910/01/2018  
CH041700WALGREEN CO.DBA: WALGREENS # 01662 4673 TAMIAMI TRL N
NAPLESFL3410301/01/2022  
CH041700WALGREEN CO.DBA: WALGREENS # 04165 28100 S. TAMIAMI TRAIL
BONITA SPRINGSFL3413401/01/2022  
CH04170FWALGREEN CO.DBA: WALGREENS # 05693 1450 IMMOKALEE DRIVE
IMMOKALEEFL3414201/01/2024  
CH04170EWALGREEN CO.DBA: WALGREENS #11658 4747 GOLDEN GATE PKWY
NAPLESFL3411601/01/2024  
CH04170LWALGREEN CO.DBA: WALGREENS # 04524 12780 TAMIAMI TRAIL E
NAPLESFL3411301/01/2024  
CH04170ZWALGREEN CO.DBA: WALGREENS #10742 30 GOLDEN GATE BLVD W
NAPLESFL3412001/01/2024 04/01/2024
CH04170QWALGREEN CO.DBA: WALGREENS # 06071 38 HOMESTEAD RD N
LEHIGH ACRESFL33936-664601/01/2024  
CH04170XWALGREEN CO.DBA: WALGREENS # 04482 1565 AIRPORT ROAD SOUTH
NAPLESFL3410401/01/2024  
CH04170AAWALGREEN CO.DBA: WALGREENS #10742 30 GOLDEN GATE BLVD W
NAPLESFL3412007/01/2024  
CH04170ABWALGREEN CO.DBA: WALGREENS #10742 30 GOLDEN GATE BLVD W
NAPLESFL3412001/01/2025 01/01/2025
CH04170ACWALGREEN CO.DBA: WALGREENS # 02542 7301 RADIO ROAD
NAPLESFL3410401/01/2025  
CH04170ADWALGREEN CO.DBA: WALGREENS # 06500 4290 TAMIAMI TRAILS EAST
NAPLESFL3411201/01/2025  
CH04170ABWALGREEN CO.DBA: WALGREENS # 06775 15295 COLLIER BLVD
NAPLESFL34119-771501/01/2025  
CH041700Walgreens #21395Walgreens Central Fill #21395 5710 Young Pine Rd
OrlandoFL3282901/01/2023  
CH04170AEWalgreens #21395Walgreens Central Fill #21395 5710 Young Pine Rd
OrlandoFL3282904/01/2025  
CH041700WALGREENS MAIL SERVICE, INC.8350 S RIVER PARKWAY
TEMPEAZ8528407/01/2015 03/05/2018
CH041700WALGREENS MAIL SERVICE, LLCWALGREENS MAIL SERVICE #03397 8350 S RIVER PARKWAY
TEMPEAZ8528401/01/2018  
CH041700WALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15438 41460 HAGGERTY CIR S
CANTONMI4818804/01/2024  
CH041700WALGREENS SPECIALTY PHARMACY, LLCDBA WALGREENS SPECIALTY PHARMACY #15443 10530 JOHN W ELLIOTT DR STE 100
FRISCOTX7503304/01/2024  
CH041700WALGREENS.COM, INC.DBA: WALGREENS 2225 S. PRICE ROAD
CHANDLERAZ8528601/01/2018  
CH041700WALMART PHARMACY 10-51692252 NORTH 8TH STREET
SUITE A
ROGERSAR7275610/01/2023  
CH041700Walmart Pharmacy 10-76112501 Perry Rd
PlainfieldIN4616804/01/2024  
CH041700WELLDYNERX  7472 S. TUSCON WAY
SUITE 100-A
CENTENNIALCO8011204/01/2015 07/02/2015
CH041700WELLDYNERX LLCDBA HEALTHDYNE PHARMACY 500 EAGLES LANDING DR
LAKELANDFL3381004/01/2015 07/02/2015
CH041700WINN DIXIE PHARMACY #7434849 GOLDEN GATE PKWY
NAPLESFL3411604/01/2016 08/08/2020
History
SectionFieldActionActivityValue BeforeValue AfterTimestamp 
Medicaid BillingNPI: NumberInsertChange Request 13369599803/10/2025 4:06 PM
Medicaid BillingNPI: StateInsertChange Request FL3/10/2025 4:06 PM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/18/2025 3:43 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0291528242/18/2025 3:43 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/18/2025 3:43 PM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/18/2025 3:43 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0291528252/18/2025 3:43 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/18/2025 3:43 PM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/18/2025 3:43 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0291528282/18/2025 3:43 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/18/2025 3:43 PM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/18/2025 3:43 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0291528292/18/2025 3:43 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/18/2025 3:43 PM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/18/2025 3:43 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0291528322/18/2025 3:43 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/18/2025 3:43 PM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/18/2025 3:43 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0291528332/18/2025 3:43 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/18/2025 3:43 PM
DetailsLast Recertification DateUpdateRecertification2/9/2024 1:35:19 PM2/18/2025 3:43:51 PM2/18/2025 3:43 PM
Medicaid BillingNPI: NumberInsertChange Request 12359467161/10/2025 2:37 PM
Medicaid BillingNPI: StateInsertChange Request FL1/10/2025 2:37 PM
Medicaid BillingNPI: NumberInsertChange Request 17804912581/10/2025 2:37 PM
Medicaid BillingNPI: StateInsertChange Request FL1/10/2025 2:37 PM
Medicaid BillingNPI: NumberInsertChange Request 15389760061/10/2025 2:37 PM
Medicaid BillingNPI: StateInsertChange Request FL1/10/2025 2:37 PM
Medicaid BillingNPI: NumberInsertChange Request 10834215561/10/2025 2:37 PM
Medicaid BillingNPI: StateInsertChange Request FL1/10/2025 2:37 PM
Medicaid BillingNPI: NumberInsertChange Request 190262147712/19/2024 2:02 PM
Medicaid BillingNPI: StateInsertChange Request FL12/19/2024 2:02 PM
Medicaid BillingNPI: NumberInsertChange Request 163999410612/19/2024 2:02 PM
Medicaid BillingNPI: StateInsertChange Request FL12/19/2024 2:02 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False11/13/2024 4:50 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395503011/13/2024 4:50 PM
Medicaid BillingMedicaid: StateInsertChange Request FL11/13/2024 4:50 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False11/13/2024 4:48 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395500711/13/2024 4:48 PM
Medicaid BillingMedicaid: StateInsertChange Request FL11/13/2024 4:48 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False11/13/2024 1:45 PM
Medicaid BillingMedicaid: NumberInsertChange Request 02915282211/13/2024 1:45 PM
Medicaid BillingMedicaid: StateInsertChange Request FL11/13/2024 1:45 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False11/13/2024 1:45 PM
Medicaid BillingMedicaid: NumberInsertChange Request 02915282311/13/2024 1:45 PM
Medicaid BillingMedicaid: StateInsertChange Request FL11/13/2024 1:45 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False11/13/2024 1:45 PM
Medicaid BillingMedicaid: NumberInsertChange Request 02915282611/13/2024 1:45 PM
Medicaid BillingMedicaid: StateInsertChange Request FL11/13/2024 1:45 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False11/13/2024 1:45 PM
Medicaid BillingMedicaid: NumberInsertChange Request 02915282711/13/2024 1:45 PM
Medicaid BillingMedicaid: StateInsertChange Request FL11/13/2024 1:45 PM
Medicaid BillingNPI: NumberInsertChange Request 179050261511/13/2024 1:45 PM
Medicaid BillingNPI: StateInsertChange Request FL11/13/2024 1:45 PM
Medicaid BillingNPI: NumberInsertChange Request 141777433211/13/2024 1:45 PM
Medicaid BillingNPI: StateInsertChange Request FL11/13/2024 1:45 PM
Medicaid BillingNPI: NumberInsertChange Request 19420599108/29/2024 1:59 PM
Medicaid BillingNPI: StateInsertChange Request FL8/29/2024 1:59 PM
Medicaid BillingNPI: NumberInsertChange Request 19329589078/29/2024 1:59 PM
Medicaid BillingNPI: StateInsertChange Request FL8/29/2024 1:59 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False7/9/2024 1:28 PM
Medicaid BillingMedicaid: NumberInsertChange Request 0291528207/9/2024 1:28 PM
Medicaid BillingMedicaid: StateInsertChange Request FL7/9/2024 1:28 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False7/9/2024 1:28 PM
Medicaid BillingMedicaid: NumberInsertChange Request 0291528217/9/2024 1:28 PM
Medicaid BillingMedicaid: StateInsertChange Request FL7/9/2024 1:28 PM
AddressesShipping AddressInsertChange Request Collier Health Services, Inc., d/b/a Healthcare Network 12655 Collier Blvd Naples, FL 341165/24/2024 9:38 AM
AddressesShipping AddressInsertChange Request Collier Health Services, Inc., Healthcare Network of Southwest Florida 12655 Collier Blvd Naples, FL 341165/24/2024 9:38 AM
Medicaid BillingNPI: NumberInsertChange Request 12551076295/23/2024 12:49 PM
Medicaid BillingNPI: StateInsertChange Request FL5/23/2024 12:49 PM
Medicaid BillingNPI: NumberInsertChange Request 11642762915/23/2024 12:49 PM
Medicaid BillingNPI: StateInsertChange Request FL5/23/2024 12:49 PM
Medicaid BillingNPI: NumberInsertChange Request 14470991065/23/2024 12:49 PM
Medicaid BillingNPI: StateInsertChange Request FL5/23/2024 12:49 PM
Medicaid BillingNPI: NumberInsertChange Request 12551709165/23/2024 12:49 PM
Medicaid BillingNPI: StateInsertChange Request FL5/23/2024 12:49 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False3/15/2024 2:26 PM
Medicaid BillingMedicaid: NumberInsertChange Request 0291528183/15/2024 2:26 PM
Medicaid BillingMedicaid: StateInsertChange Request FL3/15/2024 2:26 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False3/15/2024 2:26 PM
Medicaid BillingMedicaid: NumberInsertChange Request 0291528193/15/2024 2:26 PM
Medicaid BillingMedicaid: StateInsertChange Request FL3/15/2024 2:26 PM
Medicaid BillingNPI: NumberInsertChange Request 18713664273/15/2024 2:26 PM
Medicaid BillingNPI: StateInsertChange Request FL3/15/2024 2:26 PM
Medicaid BillingNPI: NumberInsertChange Request 18915516103/15/2024 2:26 PM
Medicaid BillingNPI: StateInsertChange Request FL3/15/2024 2:26 PM
Medicaid BillingMedicaid: NumberDeleteRecertification683955021 (FL) 2/9/2024 1:35 PM
Medicaid BillingMedicaid: NumberDeleteRecertification683955022 (FL) 2/9/2024 1:35 PM
Medicaid BillingNPI: NumberDeleteRecertification1578240503 (FL) 2/9/2024 1:35 PM
Medicaid BillingNPI: NumberDeleteRecertification1851077184 (FL) 2/9/2024 1:35 PM
Medicaid BillingNPI: NumberDeleteRecertification1780078998 (FL) 2/9/2024 1:35 PM
Medicaid BillingNPI: NumberDeleteRecertification1982098083 (FL) 2/9/2024 1:35 PM
DetailsLast Recertification DateUpdateRecertification2/7/2023 3:25:18 PM2/9/2024 1:35:19 PM2/9/2024 1:35 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 02915280310/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 06142620110/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395501210/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395501310/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395500510/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 25327780610/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 02915280510/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 25327780310/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395502410/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395502510/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 02915281010/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 02915281110/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395501710/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395501810/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395502310/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395502610/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395502110/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395502210/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395501010/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395501110/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 10289280010/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: Is PrimaryInsertChange Request False10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberInsertChange Request 68395500610/27/2023 2:21 PM
Medicaid BillingMedicaid: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberDeleteChange Request683955003 (FL) 10/27/2023 2:21 PM
Medicaid BillingMedicaid: NumberDeleteChange Request683955004 (FL) 10/27/2023 2:21 PM
Medicaid BillingNPI: NumberDeleteChange Request1417161852 (FL) 10/27/2023 2:21 PM
Medicaid BillingNPI: NumberDeleteChange Request1225243132 (FL) 10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 113433141610/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 105352696210/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 119491999310/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 137673869010/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 147722975510/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 140706131010/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 131615222610/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 185150520010/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 113433404810/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 168903104910/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 149711285810/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 157824050310/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 185107718410/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 150807924510/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 158887949810/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 165986441110/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 152856491110/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 146782942410/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 115479913810/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 178007899810/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 198209808310/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 184148451610/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 107370774110/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 118470768910/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 158802639710/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 139610710810/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 186160777210/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
Medicaid BillingNPI: NumberInsertChange Request 177079868810/27/2023 2:21 PM
Medicaid BillingNPI: StateInsertChange Request FL10/27/2023 2:21 PM
DetailsLast Recertification DateUpdateRecertification2/14/2022 1:37:43 PM2/7/2023 3:25:18 PM2/7/2023 3:25 PM
ContactsPrimary ContactUpdateProfile Change RequestWoolley, Martine Director of Pharmacy Collier Health Services, Inc. 2396583030Woolley, Martine Vice President of Pharmacy Collier Health Services, Inc. 239658303010/3/2022 11:28 AM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/14/2022 1:37 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0196121002/14/2022 1:37 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/14/2022 1:37 PM
Medicaid BillingNPI: NumberInsertRecertification 19629519962/14/2022 1:37 PM
Medicaid BillingNPI: StateInsertRecertification FL2/14/2022 1:37 PM
DetailsLast Recertification DateUpdateRecertification2/15/2021 1:17:03 PM2/14/2022 1:37:43 PM2/14/2022 1:37 PM
ContactsAuthorizing OfficialUpdateProfile Change RequestFletcher, John VP of Operations & General Counsel Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 2396583060Fletcher, John Chief Operating Officer & General Counsel Collier Health Services, Inc., d/b/a Healthcare Network 239658306011/4/2021 4:09 PM
ContactsAuthorizing OfficialUpdateProfile Change RequestFletcher, John VP of Administration & General Counsel Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 2396583060Fletcher, John VP of Operations & General Counsel Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 239658306010/12/2021 6:27 AM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/15/2021 1:17 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0291528142/15/2021 1:17 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/15/2021 1:17 PM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False2/15/2021 1:17 PM
Medicaid BillingMedicaid: NumberInsertRecertification 0291528152/15/2021 1:17 PM
Medicaid BillingMedicaid: StateInsertRecertification FL2/15/2021 1:17 PM
Medicaid BillingNPI: NumberInsertRecertification 16791240102/15/2021 1:17 PM
Medicaid BillingNPI: StateInsertRecertification FL2/15/2021 1:17 PM
Medicaid BillingNPI: StateUpdateRecertification FL2/15/2021 1:17 PM
Medicaid BillingNPI: StateUpdateRecertification FL2/15/2021 1:17 PM
DetailsLast Recertification DateUpdateRecertification1/28/2020 12:25:52 PM2/15/2021 1:17:03 PM2/15/2021 1:17 PM
AddressesBilling AddressUpdateChange RequestCollier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 1454 Madison Ave W Immokalee, FL 34142Collier Health Services, Inc., d/b/a Healthcare Network 1454 Madison Ave W Immokalee, FL 341426/4/2020 11:49 AM
AddressesMain AddressUpdateChange Request 1755 HERITAGE TRAIL 601 NAPLES, FL 34112-7591 12655 Collier Blvd NAPLES, FL 34116-75916/4/2020 11:49 AM
DetailsEntity SubnameUpdateChange RequestEAST NAPLES MEDICAL CENTERNichols Community Health Center6/4/2020 11:49 AM
ContactsAuthorizing OfficialUpdateChange RequestEllis, Mike President/CEO Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 2396583158Fletcher, John VP of Administration & General Counsel Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 23965830601/29/2020 11:03 AM
ContactsPrimary ContactUpdateRecertificationFletcher, John General Counsel Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 2396583060Woolley, Martine Director of Pharmacy Collier Health Services, Inc. 23965830301/28/2020 12:25 PM
DetailsLast Recertification DateUpdateRecertification2/20/2019 11:30:45 AM1/28/2020 12:25:52 PM1/28/2020 12:25 PM
DetailsLast Recertification DateUpdateRecertification3/6/2018 9:58:14 AM2/20/2019 11:30:45 AM2/20/2019 11:30 AM
AddressesBilling AddressInsertRecertification Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 1454 Madison Ave W Immokalee, FL 341423/6/2018 9:58 AM
AddressesMain AddressUpdateRecertification 1755 HERITAGE TRAIL STE 601 NAPLES, FL 34112-7591 1755 HERITAGE TRAIL 601 NAPLES, FL 34112-75913/6/2018 9:58 AM
Medicaid BillingMedicaid: NumberUpdateRecertification0291528056839550033/6/2018 9:58 AM
Medicaid BillingMedicaid: Is PrimaryInsertRecertification False3/6/2018 9:58 AM
Medicaid BillingMedicaid: NumberInsertRecertification 6839550043/6/2018 9:58 AM
Medicaid BillingMedicaid: StateInsertRecertification FL3/6/2018 9:58 AM
Medicaid BillingNPI: NumberUpdateRecertification113433404814171618523/6/2018 9:58 AM
Medicaid BillingNPI: NumberUpdateRecertification185150520012252431323/6/2018 9:58 AM
DetailsLast Recertification DateUpdateRecertification2/8/2017 12:00:00 AM3/6/2018 9:58:14 AM3/6/2018 9:58 AM
DetailsIs Authorizing Official EHB DataUpdateRecertificationFalse 3/6/2018 9:58 AM
ContactsAuthorizing OfficialUpdate Ellis, Mike President/CEO 2396583158Ellis, Mike President/CEO Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 239658315810/11/2017 11:46 AM
ContactsSigned ByUpdate Ellis, Mike President/CEO 2396583158Ellis, Mike President/CEO Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 239658315810/11/2017 11:46 AM
ContactsPrimary ContactUpdate Fletcher, John General Counsel 2396583060Fletcher, John General Counsel Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida 23965830609/18/2017 4:17 PM
ContactsAuthorizing OfficialInsert  Ellis, Mike President/CEO 23965831587/18/2017 9:23 AM
ContactsSigned ByInsert  Ellis, Mike President/CEO 23965831587/18/2017 9:23 AM
ContactsPrimary ContactUpdate Allen, Larry CIO 2396583022Fletcher, John General Counsel 23965830607/17/2017 11:08 AM
AddressesMain AddressInsert   1755 HERITAGE TRAIL STE 601 NAPLES, FL 34112-75913/9/2017 4:51 PM
Medicaid BillingMedicaid: Is PrimaryInsert  False3/9/2017 4:50 PM
Medicaid BillingMedicaid: NumberInsert  0291528053/9/2017 4:50 PM
Medicaid BillingMedicaid: StateInsert  FL3/9/2017 4:50 PM
Medicaid BillingNPI: NumberInsert  11343340483/9/2017 4:50 PM
Medicaid BillingNPI: NumberInsert  18515052003/9/2017 4:50 PM
DetailsLast Recertification DateUpdate 2/29/2016 12:00:00 AM2/8/2017 12:00:00 AM2/8/2017 4:00 PM
ContactsPrimary ContactInsert  Allen, Larry CIO 239658302210/13/2016 2:02 PM
DetailsLast Recertification DateUpdate  2/29/2016 12:00:00 AM2/29/2016 4:06 PM
DatesParticipating Approval DateUpdate  7/6/2015 12:00:00 AM7/6/2015 4:50 PM
DetailsStateUpdate PendingActive7/6/2015 4:50 PM
DatesStart DateUpdate  10/1/2015 12:00:00 AM7/6/2015 4:50 PM
Details340B IDUpdate ONLINE_REG_52034CH04170M7/2/2015 12:49 PM
Details340B IDUpdate ONLINE_REGONLINE_REG_520347/1/2015 1:44 PM
DetailsLast Recertification DateInsert   7/1/2015 1:44 PM
DetailsGrant NumberInsert  H80CS007357/1/2015 1:44 PM
Details340B IDInsert  ONLINE_REG7/1/2015 1:44 PM
DetailsIs Authorizing Official EHB DataInsert  False7/1/2015 1:44 PM
DatesLast Date That 340B Drugs PurchasedInsert   7/1/2015 1:44 PM
DetailsMedicare Provider NumberInsert   7/1/2015 1:44 PM
DetailsEntity NameInsert  COLLIER HEALTH SERVICES, INC.7/1/2015 1:44 PM
DetailsProgram CodeInsert  CH7/1/2015 1:44 PM
DetailsEntity SubnameInsert  EAST NAPLES MEDICAL CENTER7/1/2015 1:44 PM
DatesParticipating Approval DateInsert   7/1/2015 1:44 PM
DetailsStateInsert  Pending7/1/2015 1:44 PM
DatesRegistration DateInsert  7/1/2015 12:00:00 AM7/1/2015 1:44 PM
DatesSigned By DateInsert  7/1/2015 12:00:00 AM7/1/2015 1:44 PM
DatesStart DateInsert   7/1/2015 1:44 PM
TerminationsTermination CommentsInsert   7/1/2015 1:44 PM
TerminationsTermination DateInsert   7/1/2015 1:44 PM
TerminationsTermination Effective DateInsert   7/1/2015 1:44 PM
TerminationsTermination ReasonInsert   7/1/2015 1:44 PM