Covered Entity Details

DSH100132A SOUTH FLORIDA BAPTIST HOSPITAL (Terminated) - information as of 5/24/2025 12:39:07 AM

Main Details

Name

SOUTH FLORIDA BAPTIST HOSPITAL

Subdivision Name

Outpatient Infusion

Type

Disproportionate Share Hospital

Rural

340B ID

DSH100132A

Medicare Provider Number

100132

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

10/17/2016

Participating Start Date

1/1/2017

Participating Approval Date

11/1/2016

Last Recertification Date

8/20/2019

Termination Date
Termination Reason

1/1/2020
Outpatient facility moved within the 4 walls of the parent hospital

Contacts

Authorizing Official

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

Primary Contact

BayCare Health System
Michael Magee, Vice President of Pharmacy
(813) 870-4020

Addresses

Street Address

301 N. Alexander St
Plant City, FL 33563-4303

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
FL	0100986-00
		1548205883

Shipping Addresses

Shipping Address 1

Outpatient Infusion
301 N. Alexander St
Plant City, FL 33563-4303

Shipping Address 2

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

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH100132A	Child	DSH	SOUTH FLORIDA BAPTIST HOSPITAL	Outpatient Infusion	301 N. Alexander St	Plant City	FL	Terminated
DSH100132B	Child	DSH	SOUTH FLORIDA BAPTIST HOSPITAL	SO FLA BAPTIST OUTPATIENT INFUSION - Outpatient Infusion	3198 N PARK ROAD	PLANT CITY	FL	Active
DSH100132C	Child	DSH	SOUTH FLORIDA BAPTIST HOSPITAL	SO FLA BAPTIST HOSPITAL WOUND CARE - Wound Care Center	3198 N PARK ROAD	PLANT CITY	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2020 12:05 AM
Details	State	Update	Termination Request	Active	To Be Terminated	10/17/2019 9:25 AM
Terminations	Termination Date	Update	Termination Request		1/1/2020 12:00:00 AM	10/17/2019 9:25 AM
Terminations	Termination Effective Date	Update	Termination Request		1/1/2020 12:00:00 AM	10/17/2019 9:25 AM
Terminations	Termination Reason	Update	Termination Request		Outpatient facility moved within the 4 walls of the parent hospital	10/17/2019 9:25 AM
Details	Last Recertification Date	Update	Recertification	8/20/2018 2:34:00 PM	8/20/2019 9:13:56 AM	8/20/2019 9:13 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 8:40:34 AM	8/20/2018 2:34:00 PM	8/20/2018 2:34 PM
Addresses	Shipping Address	Insert	Change Request		Outpatient Infusion 301 N. Alexander St Plant City, FL 33563-4303	8/7/2018 12:52 PM
Addresses	Shipping Address	Insert	Change Request		BayCare Integrated Service Center, LLC Dba/ BayCare Central Pharmacy 7802 E. Telecom Parkway Temple Terrace, FL 33637	8/7/2018 12:52 PM
Details	Last Recertification Date	Update	Recertification		11/9/2017 8:40:34 AM	11/9/2017 8:40 AM
Contacts	Authorizing Official	Update		Tremonti, Carl Chief Financial Officer 8138704020	Tremonti, Carl Chief Financial Officer Baycare Health System 8138704020	10/2/2017 2:52 PM
Contacts	Signed By	Update		Tremonti, Carl Chief Financial Officer 8138704020	Tremonti, Carl Chief Financial Officer Baycare Health System 8138704020	10/2/2017 2:52 PM
Contacts	Primary Contact	Update		Magee, Michael Vice President of Pharmacy 8138704020	Magee, Michael Vice President of Pharmacy BayCare Health System 8138704020	10/1/2017 6:33 PM
Contacts	Authorizing Official	Insert			Tremonti, Carl Chief Financial Officer 8138704020	8/9/2017 10:58 AM
Contacts	Signed By	Insert			Tremonti, Carl Chief Financial Officer 8138704020	8/9/2017 10:58 AM
Contacts	Primary Contact	Insert			Magee, Michael Vice President of Pharmacy 8138704020	8/4/2017 1:11 PM
Addresses	Main Address	Insert			301 N. Alexander St Plant City, FL 33563-4303	11/1/2016 2:10 PM
Dates	Participating Approval Date	Update			11/1/2016 12:00:00 AM	11/1/2016 2:10 PM
Details	State	Update		Pending	Active	11/1/2016 2:10 PM
Dates	Start Date	Update			1/1/2017 12:00:00 AM	11/1/2016 2:10 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_73474	DSH100132A	11/1/2016 10:29 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_73474	10/17/2016 3:01 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/17/2016 3:01 PM
Medicaid Billing	Medicaid: Number	Insert			0100986-00	10/17/2016 3:01 PM
Medicaid Billing	Medicaid: State	Insert			FL	10/17/2016 3:01 PM
Medicaid Billing	NPI: Number	Insert			1548205883	10/17/2016 3:01 PM
Details	Last Recertification Date	Insert				10/17/2016 3:01 PM
Details	Grant Number	Insert				10/17/2016 3:01 PM
Details	340B ID	Insert				10/17/2016 3:01 PM
Details	Is Authorizing Official EHB Data	Insert				10/17/2016 3:01 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/17/2016 3:01 PM
Details	Medicare Provider Number	Insert			100132	10/17/2016 3:01 PM
Details	Entity Name	Insert			SOUTH FLORIDA BAPTIST HOSPITAL	10/17/2016 3:01 PM
Details	Program Code	Insert			DSH	10/17/2016 3:01 PM
Details	Entity Subname	Insert			Outpatient Infusion	10/17/2016 3:01 PM
Dates	Participating Approval Date	Insert				10/17/2016 3:01 PM
Details	State	Insert			Pending	10/17/2016 3:01 PM
Dates	Registration Date	Insert			10/17/2016 12:00:00 AM	10/17/2016 3:01 PM
Dates	Signed By Date	Insert			10/17/2016 12:00:00 AM	10/17/2016 3:01 PM
Dates	Start Date	Insert				10/17/2016 3:01 PM
Terminations	Termination Comments	Insert				10/17/2016 3:01 PM
Terminations	Termination Date	Insert				10/17/2016 3:01 PM
Terminations	Termination Effective Date	Insert				10/17/2016 3:01 PM
Terminations	Termination Reason	Insert				10/17/2016 3:01 PM