Covered Entity Details

DSH100088AU BAPTIST MEDICAL CENTER (Active) - information as of 5/17/2025 10:56:25 PM

Main Details

Name

BAPTIST MEDICAL CENTER

Subdivision Name

Baptist Jacksonville Infusion Services

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH100088AU

Medicare Provider Number

100088

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/13/2018

Participating Start Date

7/1/2018

Participating Approval Date

4/24/2018

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Baptist Medical Center
Scott Finnegan, Senior Vice President of Finance/Treasury
(904) 202-3270

Primary Contact

Baptist Medical Center
Pamela Michelle Johnston, Sr 340B Pharmacy Specialist
(904) 202-5255

Addresses

Street Address

1235 San Marco Blvd
2nd Floor
Jacksonville, FL 32207

Billing Address

Baptist Medical Center
PO BOX 45128
Jacksonville, FL 32232

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	010064106,010064100	1578620449,1316112014,1457526154,1972044857,1700553856
GA	000103771A	1578620449,1316112014,1457526154,1972044857,1700553856
AL		1578620449,1316112014,1457526154,1972044857,1700553856
MS		1578620449,1316112014,1457526154,1972044857,1700553856
SC		1578620449,1316112014,1457526154,1972044857,1700553856

Shipping Addresses

Shipping Address 1

Baptist MD Anderson Cancer Center
1301 Palm Ave
9th Floor
Jacksonville, FL 32207

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
DSH100088A	Child	DSH	BAPTIST MEDICAL CENTER	BAPTIST MEDICAL CENTER SOUTH	14550 OLD ST AUGUSTINE RD	JACKSONVILLE	FL	Active
DSH100088AA	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Endoscopy	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AB	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Emergency Services	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AC	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Recovery Services	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AD	Child	DSH	BAPTIST MEDICAL CENTER	South MOB ll-O/P Surgery Center	14540 Old St. Augustine Rd	Jacksonville	FL	Terminated
DSH100088AE	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Surgical Services	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AF	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-MRI	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AG	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Special Procedures	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AH	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Nuclear Medicine	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AJ	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Radiology	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AK	Child	DSH	BAPTIST MEDICAL CENTER	Cardiology/Nuc Med South- Baptist Heart	14534 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088AL	Child	DSH	BAPTIST MEDICAL CENTER	BMDACC Infusion Center	1301 Palm Ave	Jacksonville	FL	Active
DSH100088AM	Child	DSH	BAPTIST MEDICAL CENTER	Cardiology Pavilion- Baptist Heart	836 Prudential Dr	Jacksonville	FL	Active
DSH100088AN	Child	DSH	BAPTIST MEDICAL CENTER	Cardiac Nuc Med University- Baptist Heart	3225 University Blvd S	Jacksonville	FL	Active
DSH100088AP	Child	DSH	BAPTIST MEDICAL CENTER	Cardiac Nuc Med- Pavilion Baptist Heart	836 Prudential Dr	Jacksonville	FL	Active
DSH100088AQ	Child	DSH	BAPTIST MEDICAL CENTER	Cardiology Howard SHG	820 Prudential Dr	Jacksonville	FL	Terminated
DSH100088AR	Child	DSH	BAPTIST MEDICAL CENTER	BAPTIST EMERGENCY CENTER AT CLAY	1771 BAPTIST CLAY RD	FLEMING ISLAND	FL	Active
DSH100088AS	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Emergency at Town Center	4085 Town Center Parkway	Jacksonville	FL	Active
DSH100088AT	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Emergency at North	11250 Baptist Health Drive	Jacksonville	FL	Active
DSH100088AU	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Jacksonville Infusion Services	1235 San Marco Blvd	Jacksonville	FL	Active
DSH100088AV	Child	DSH	BAPTIST MEDICAL CENTER	BMDA South Infusion Center	14546 Old St Augustine Rd	Jacksonville	FL	Active
DSH100088AW	Child	DSH	BAPTIST MEDICAL CENTER	WCH Infusion Center at Nemours - Infusion	807 Childrens Way	Jacksonville	FL	Active
DSH100088AX	Child	DSH	BAPTIST MEDICAL CENTER	BAPTIST CLAY- Surgical Services	1771 BAPTIST CLAY DR	FLEMING ISLAND	FL	Active
DSH100088AY	Child	DSH	BAPTIST MEDICAL CENTER	BAPTIST OAKLEAF - Emergency Center	9868 FAMILY PLACE	JACKSONVILLE	FL	Active
DSH100088AZ	Child	DSH	BAPTIST MEDICAL CENTER	Head/Neck Surgery - BMDA	1301 Palm Ave	Jacksonville	FL	Terminated
DSH100088B	Child	DSH	BAPTIST MEDICAL CENTER	BAPTIST HOME HEALTH CARE	3563 PHILIPS HIGHWAY	JACKSONVILLE	FL	Terminated
DSH100088BA	Child	DSH	BAPTIST MEDICAL CENTER	Colorectal GI Surgery - BMDA	1301 Palm Ave	Jacksonville	FL	Terminated
DSH100088BB	Child	DSH	BAPTIST MEDICAL CENTER	Orthopedic Surgery - BMDA	1301 Palm Ave	Jacksonville	FL	Terminated
DSH100088BC	Child	DSH	BAPTIST MEDICAL CENTER	Surgical Oncology - BMDA	1301 Palm Ave	Jacksonville	FL	Active
DSH100088BD	Child	DSH	BAPTIST MEDICAL CENTER	Thoracic Surgery - BMDA	1301 Palm Ave	Jacksonville	FL	Terminated
DSH100088BE	Child	DSH	BAPTIST MEDICAL CENTER	Urology Oncology Surgery - BMDA	1301 Palm Ave	Jacksonville	FL	Terminated
DSH100088BF	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Clay- Heart Center - Baptist Heart	2310 Village Square Parkway Suite 104	Fleming Island	FL	Active
DSH100088BG	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Clay- MRI - MRI	1771 Baptist Clay Dr	Fleming Island	FL	Active
DSH100088BH	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Clay- Mammography - Mammography	2310 Village Square Parkway Suite 104	Fleming Island	FL	Active
DSH100088BJ	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Clay- Recovery Services - Recovery	1771 Baptist Clay Dr	Fleming Island	FL	Active
DSH100088BK	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Clay- Endoscopy - Endoscopy	1771 Baptist Clay Dr	Fleming Island	FL	Active
DSH100088BL	Child	DSH	BAPTIST MEDICAL CENTER	BMDA Clay- Radiation Therapy - Radiation	2310 Village Square Parkway	Fleming Island	FL	Active
DSH100088BM	Child	DSH	BAPTIST MEDICAL CENTER	BMDA Clay- Infusion Center - Infusion	2310 Village Square Parkway	Fleming Island	FL	Active
DSH100088BN	Child	DSH	BAPTIST MEDICAL CENTER	BAPTIST CLAY - Medical Surgical services/Observation	1771 BAPTIST CLAY DR	FLEMING ISLAND	FL	Active
DSH100088BP	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Emergency- St Augustine - Emergency	461 Outlet Mall Blvd	St Augustine	FL	Approved
DSH100088C	Child	DSH	BAPTIST MEDICAL CENTER	BAPTIST OUTPATIENT CENTER OR	1235 SAN MARCO BOULEVARD	JACKSONVILLE	FL	Terminated
DSH100088D	Child	DSH	BAPTIST MEDICAL CENTER	REID MEDICAL BUILDING	1325 SAN MARCO BOULEVARD	JACKSONVILLE	FL	Terminated
DSH100088E	Child	DSH	BAPTIST MEDICAL CENTER	CHILDREN'S CARDIOLOGY CENTER	841 Prudential Drive	JACKSONVILLE	FL	Active
DSH100088F	Child	DSH	BAPTIST MEDICAL CENTER	AgeWell Institute	841 Prudential Drive	Jacksonville	FL	Terminated
DSH100088G	Child	DSH	BAPTIST MEDICAL CENTER	Cardiology University- Baptist Heart	3225 University Blvd. S.	Jacksonville	FL	Active
DSH100088H	Child	DSH	BAPTIST MEDICAL CENTER	Cardiac Nuc Med Howard SHG	820 Prudential Dr	Jacksonville	FL	Terminated
DSH100088J	Child	DSH	BAPTIST MEDICAL CENTER	BMDA-Medical & Surgical Oncology Breast/GYN	1301 Palm Ave	Jacksonville	FL	Terminated
DSH100088K	Child	DSH	BAPTIST MEDICAL CENTER	BMDACC-Radiation Therapy	1301 Palm Ave	Jacksonville	FL	Active
DSH100088L	Child	DSH	BAPTIST MEDICAL CENTER	BMDACC- Imaging Services	1301 Palm Ave	Jacksonville	FL	Active
DSH100088M	Child	DSH	BAPTIST MEDICAL CENTER	Outpatient Center-Breast Center	1235 San Marco Blvd	Jacksonville	FL	Active
DSH100088N	Child	DSH	BAPTIST MEDICAL CENTER	JOI/Reid Building- MRI	1325 San Marco Blvd	Jacksonville	FL	Terminated
DSH100088P	Child	DSH	BAPTIST MEDICAL CENTER	JOI/Reid Building-OR	1325 San Marco Blvd	Jacksonville	FL	Active
DSH100088Q	Child	DSH	BAPTIST MEDICAL CENTER	WCH Outpatient Surgery	836 Prudential Dr	Jacksonville	FL	Active
DSH100088R	Child	DSH	BAPTIST MEDICAL CENTER	Imaging Center Building-Mammography	1771 Baptist Clay Drive	Fleming Island	FL	Terminated
DSH100088S	Child	DSH	BAPTIST MEDICAL CENTER	Imaging Center Building-Cat Scan	1771 Baptist Clay Drive	Fleming Island	FL	Terminated
DSH100088T	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Clay-Diagnostic Radiology	1771 Baptist Clay Drive	Fleming Island	FL	Active
DSH100088U	Child	DSH	BAPTIST MEDICAL CENTER	MOB-Cardiology/Nuc Med CLY	1771 Baptist Clay Drive	Fleming Island	FL	Active
DSH100088V	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Cath Lab	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088W	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-CardioPulmonary	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088X	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Anesthesia	14550 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088Y	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-Radiation Therapy	14546 Old St. Augustine Rd	Jacksonville	FL	Active
DSH100088Z	Child	DSH	BAPTIST MEDICAL CENTER	Baptist Medical Center South-O/P Diagnostic Imaging	14534 Old St. Augustine Rd	Jacksonville	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/24/2023 9:25:25 AM	8/26/2024 8:42:14 AM	8/26/2024 8:42 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 1:07:56 PM	8/24/2023 9:25:25 AM	8/24/2023 9:25 AM
Details	Last Recertification Date	Update	Recertification	8/30/2021 7:14:27 AM	9/8/2022 1:07:56 PM	9/8/2022 1:07 PM
Addresses	Billing Address	Update	Group Change Request	Baptist Medical Center PO Box 45094 Jacksonville, FL 32232	Baptist Medical Center PO BOX 45128 Jacksonville, FL 32232	4/16/2022 5:04 PM
Contacts	Authorizing Official	Update	Change Request	Wooten, Scott M. SVP & CFO Baptist Medical Center 9042023405	Finnegan, Scott Senior Vice President of Finance/Treasury Baptist Medical Center 9042023270	1/7/2022 11:49 AM
Contacts	Primary Contact	Update	Profile Change Request	Johnston, Pamela Michelle Financial Analyst I Baptist Medical Center 9042025255	Johnston, Pamela Michelle Sr 340B Pharmacy Specialist Baptist Medical Center 9042025255	1/6/2022 10:35 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700553856	10/27/2021 9:17 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AL	10/27/2021 9:17 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700553856	10/27/2021 9:17 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		FL	10/27/2021 9:17 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700553856	10/27/2021 9:17 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		GA	10/27/2021 9:17 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700553856	10/27/2021 9:17 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		MS	10/27/2021 9:17 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1700553856	10/27/2021 9:17 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		SC	10/27/2021 9:17 AM
Details	Last Recertification Date	Update	Recertification	8/28/2020 1:37:58 PM	8/30/2021 7:14:27 AM	8/30/2021 7:14 AM
Addresses	Main Address	Update	Change Request	1301 Palm Ave 9th Floor Jacksonville, FL 32207	1235 San Marco Blvd 2nd Floor Jacksonville, FL 32207	12/18/2020 4:39 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1578620449	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1316112014	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457526154	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972044857	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		GA	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1578620449	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1316112014	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457526154	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972044857	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972044857	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		AL	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1578620449	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1316112014	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457526154	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972044857	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		MS	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1578620449	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1316112014	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1457526154	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/28/2020 1:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1972044857	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Update	Recertification		AL	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Update	Recertification		AL	8/28/2020 1:37 PM
Medicaid Billing	NPI: State	Update	Recertification		AL	8/28/2020 1:37 PM
Details	Last Recertification Date	Update	Recertification	9/8/2019 9:36:47 AM	8/28/2020 1:37:58 PM	8/28/2020 1:37 PM
Addresses	Main Address	Update	Recertification	836 Prudential Drive 4th Floor Jacksonville, FL 32207	1301 Palm Ave 9th Floor Jacksonville, FL 32207	9/8/2019 9:36 AM
Addresses	Shipping Address	Insert	Recertification		Baptist MD Anderson Cancer Center 1301 Palm Ave 9th Floor Jacksonville, FL 32207	9/8/2019 9:36 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 10:09:45 AM	9/8/2019 9:36:47 AM	9/8/2019 9:36 AM
Addresses	Billing Address	Insert	Change Request		Baptist Medical Center PO Box 45094 Jacksonville, FL 32232	9/18/2018 5:58 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/18/2018 5:58 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010064106	9/18/2018 5:58 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	9/18/2018 5:58 PM
Details	Entity Subname	Update	Change Request	Jacksonville Infusion Services - Infusion	Baptist Jacksonville Infusion Services	9/18/2018 5:58 PM
Details	Last Recertification Date	Update	Recertification		8/15/2018 10:09:45 AM	8/15/2018 10:09 AM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Wooten, Scott M. SVP & CFO Baptist Medical Center 9042023405	4/24/2018 10:53 AM
Details	340B ID	Update	New Registration		DSH100088AU	4/24/2018 10:53 AM
Details	Entity Subname	Update	New Registration	Jacksonville Infusion Services	Jacksonville Infusion Services - Infusion	4/24/2018 10:53 AM
Dates	Participating Approval Date	Update	New Registration		4/24/2018 10:53:54 AM	4/24/2018 10:53 AM
Details	State	Update	New Registration	Pending	Approved	4/24/2018 10:53 AM
Dates	Signed By Date	Update	New Registration		4/13/2018 1:49:24 PM	4/24/2018 10:53 AM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	4/24/2018 10:53 AM
Addresses	Main Address	Insert	New Registration		836 Prudential Drive 4th Floor Jacksonville, FL 32207	4/13/2018 11:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2018 11:01 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010064100	4/13/2018 11:01 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/13/2018 11:01 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/13/2018 11:01 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000103771A	4/13/2018 11:01 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/13/2018 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1578620449	4/13/2018 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1316112014	4/13/2018 11:01 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1457526154	4/13/2018 11:01 AM
Contacts	Primary Contact	Insert	New Registration		Johnston, Pamela Michelle Financial Analyst I Baptist Medical Center 9042025255	4/13/2018 11:01 AM
Contacts	Authorizing Official	Insert	New Registration		Wooten, Scott M. SVP & CFO Baptist Medical Center 9042023405	4/13/2018 11:01 AM
Details	Last Recertification Date	Insert	New Registration			4/13/2018 11:01 AM
Details	Grant Number	Insert	New Registration			4/13/2018 11:01 AM
Details	340B ID	Insert	New Registration			4/13/2018 11:01 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/13/2018 11:01 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/13/2018 11:01 AM
Details	Medicare Provider Number	Insert	New Registration		100088	4/13/2018 11:01 AM
Details	Entity Name	Insert	New Registration		BAPTIST MEDICAL CENTER	4/13/2018 11:01 AM
Details	Program Code	Insert	New Registration		DSH	4/13/2018 11:01 AM
Details	Entity Subname	Insert	New Registration		Jacksonville Infusion Services	4/13/2018 11:01 AM
Dates	Participating Approval Date	Insert	New Registration			4/13/2018 11:01 AM
Details	State	Insert	New Registration		Pending	4/13/2018 11:01 AM
Dates	Registration Date	Insert	New Registration		4/13/2018 11:01:38 AM	4/13/2018 11:01 AM
Dates	Signed By Date	Insert	New Registration			4/13/2018 11:01 AM
Dates	Start Date	Insert	New Registration			4/13/2018 11:01 AM
Terminations	Termination Comments	Insert	New Registration			4/13/2018 11:01 AM
Terminations	Termination Date	Insert	New Registration			4/13/2018 11:01 AM
Terminations	Termination Effective Date	Insert	New Registration			4/13/2018 11:01 AM
Terminations	Termination Reason	Insert	New Registration			4/13/2018 11:01 AM