Covered Entity Details

PED103301-11 Nicklaus Children's Hospital (Active) - information as of 5/27/2025 11:35:37 PM

Main Details

Name

Nicklaus Children's Hospital

Subdivision Name

Nicklaus Children's Homestead Outpatient Center - UCC

Type

Children's Hospital

Rural

340B ID

PED103301-11

Medicare Provider Number

103301

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

9/5/2019

Participating Start Date

10/1/2019

Participating Approval Date

9/10/2019

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

Nicklaus Children's Health System
Dawn Javersack, Sr. Vice President and Chief Financial Officer
(786) 624-2005

Primary Contact

Nicklaus Children's Hospital
Acirema Bastida, Pharmacy 340B Analyst
(786) 624-5789

Addresses

Street Address

2072 NE 8th Street
Homestead, FL 33033

Billing Address

Nicklaus Children's Hospital
3100 SW 62nd Avenue
Miami, FL 33155

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	010060926,10060900	1386143485,1871540237

Shipping Addresses

Shipping Address 1

Nicklaus Children's Hospital
3100 SW 62nd Avenue
Miami, FL 33155

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
PED103301-01	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Dan Marino Outpatient Center	2900 South Commerce Parkway	Weston	FL	Active
PED103301-02	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Doral Outpatient Center	3601 NW 107th Ave	Doral	FL	Active
PED103301-03	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Nirvair Chowdhury Midtown Center	3915 Biscayne Boulevard	Miami	FL	Active
PED103301-04	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Miramar Outpatient Center	12246 Miramar Parkway	Miramar	FL	Active
PED103301-05	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Palm Beach GardensOutpatient Center	11310 Legacy Ave	Palm Beach Gardens	FL	Active
PED103301-06	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Palmetto Bay Outpatient Center	17615 SW 97 Avenue	Palmetto Bay	FL	Active
PED103301-07	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's West Kendall Outpatient Center	13400 SW 120th Street	Miami	FL	Active
PED103301-08	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Miami Lakes Outpatient Center	15025 NW 77 AVENUE	MIAMI LAKES	FL	Active
PED103301-09	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's West Bird Outpatient Center	11449 SW 40 Street	MIAMI	FL	Active
PED103301-10	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Pinecrest Urgent Care Center - Urgent Care	11521 South Dixie Highway	Pinecrest	FL	Terminated
PED103301-11	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Homestead Outpatient Center - UCC	2072 NE 8th Street	Homestead	FL	Active
PED103301-12	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Hialeah Outpatient Center - Urgent Care	990 W 49th Street	Hialeah	FL	Active
PED103301-13	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Pediatric Specialists Palm City - Clinic	3228 SW Martin Downs Blvd #33	Palm City	FL	Terminated
PED103301-14	Child	PED	Nicklaus Children's Hospital	Nicklaus Children's Pediatric Specialists at Allapattah - Clinic	3445 NW 7th St	Miami	FL	Terminated
PED103301-15	Child	PED	Nicklaus Children's Hospital	Nicklaus Children’s Aventura Care Center - Clinic	20295 NE 29th Pl	Aventura	FL	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Main Address	Update	Change Request	2072 NE 8 Street Homestead, FL 33033	2072 NE 8th Street Homestead, FL 33033	3/11/2025 12:16 PM
Addresses	Billing Address	Update	Change Request	Nicklaus Children's Hospital 3100 SW 62 Avenue Miami, FL 33155	Nicklaus Children's Hospital 3100 SW 62nd Avenue Miami, FL 33155	3/11/2025 12:16 PM
Addresses	Shipping Address	Insert	Change Request		Nicklaus Children's Hospital 3100 SW 62nd Avenue Miami, FL 33155	3/11/2025 12:16 PM
Contacts	Authorizing Official	Update	Change Request	Reed, Perry Ann COO & President NIcklaus Children's Health System 7866242032	Javersack, Dawn Sr. Vice President and Chief Financial Officer Nicklaus Children's Health System 7866242005	1/27/2025 7:44 AM
Details	Last Recertification Date	Update	Recertification	9/8/2023 2:52:30 PM	8/27/2024 10:35:08 AM	8/27/2024 10:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/7/2024 1:25 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		10060900	5/7/2024 1:25 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	5/7/2024 1:25 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1871540237	5/7/2024 1:25 PM
Medicaid Billing	NPI: State	Insert	Change Request		FL	5/7/2024 1:25 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 9:12:26 AM	9/8/2023 2:52:30 PM	9/8/2023 2:52 PM
Details	Last Recertification Date	Update	Recertification	8/26/2021 1:32:43 PM	9/8/2022 9:12:26 AM	9/8/2022 9:12 AM
Details	Last Recertification Date	Update	Recertification	8/21/2020 9:12:27 AM	8/26/2021 1:32:43 PM	8/26/2021 1:32 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1386143485 ( )		8/21/2020 9:12 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1386143485	8/21/2020 9:12 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	8/21/2020 9:12 AM
Details	Last Recertification Date	Update	Recertification		8/21/2020 9:12:27 AM	8/21/2020 9:12 AM
Contacts	Authorizing Official	Update	Change Request	Perdomo, Jose Interim President and COO Nicklaus Children's Hospital 3056666511-2010	Reed, Perry Ann COO & President NIcklaus Children's Health System 7866242032	7/29/2020 8:21 AM
Contacts	Primary Contact	Update	Change Request	Bastida, Acirema Pharmacy 340B Analyst Nicklaus Children's Hospital 7866245789	Bastida, Acirema Pharmacy 340B Analyst Nicklaus Children's Hospital 7866245789	10/25/2019 1:40 PM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		Perdomo, Jose Interim President and COO Nicklaus Children's Hospital 3056666511-2010	9/10/2019 2:08 PM
Details	340B ID	Update	New Registration		PED103301-11	9/10/2019 2:08 PM
Details	Entity Subname	Update	New Registration	Nicklaus Children's Homestead Outpatient Center	Nicklaus Children's Homestead Outpatient Center - UCC	9/10/2019 2:08 PM
Dates	Participating Approval Date	Update	New Registration		9/10/2019 2:08:36 PM	9/10/2019 2:08 PM
Details	State	Update	New Registration	Pending	Approved	9/10/2019 2:08 PM
Dates	Signed By Date	Update	New Registration		9/5/2019 3:44:06 PM	9/10/2019 2:08 PM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	9/10/2019 2:08 PM
Addresses	Main Address	Insert	New Registration		2072 NE 8 Street Homestead, FL 33033	9/5/2019 12:52 PM
Addresses	Billing Address	Insert	New Registration		Nicklaus Children's Hospital 3100 SW 62 Avenue Miami, FL 33155	9/5/2019 12:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	9/5/2019 12:52 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		010060926	9/5/2019 12:52 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	9/5/2019 12:52 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1386143485	9/5/2019 12:52 PM
Contacts	Primary Contact	Insert	New Registration		Bastida, Acirema Pharmacy 340B Analyst Nicklaus Children's Hospital 7866245789	9/5/2019 12:52 PM
Contacts	Authorizing Official	Insert	New Registration		Perdomo, Jose Interim President and COO Nicklaus Children's Hospital 3056666511-2010	9/5/2019 12:52 PM
Details	Last Recertification Date	Insert	New Registration			9/5/2019 12:52 PM
Details	Grant Number	Insert	New Registration			9/5/2019 12:52 PM
Details	340B ID	Insert	New Registration			9/5/2019 12:52 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			9/5/2019 12:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			9/5/2019 12:52 PM
Details	Medicare Provider Number	Insert	New Registration		103301	9/5/2019 12:52 PM
Details	Entity Name	Insert	New Registration		Nicklaus Children's Hospital	9/5/2019 12:52 PM
Details	Program Code	Insert	New Registration		PED	9/5/2019 12:52 PM
Details	Entity Subname	Insert	New Registration		Nicklaus Children's Homestead Outpatient Center	9/5/2019 12:52 PM
Dates	Participating Approval Date	Insert	New Registration			9/5/2019 12:52 PM
Details	State	Insert	New Registration		Pending	9/5/2019 12:52 PM
Dates	Registration Date	Insert	New Registration		9/5/2019 12:52:44 PM	9/5/2019 12:52 PM
Dates	Signed By Date	Insert	New Registration			9/5/2019 12:52 PM
Dates	Start Date	Insert	New Registration			9/5/2019 12:52 PM
Terminations	Termination Comments	Insert	New Registration			9/5/2019 12:52 PM
Terminations	Termination Date	Insert	New Registration			9/5/2019 12:52 PM
Terminations	Termination Effective Date	Insert	New Registration			9/5/2019 12:52 PM
Terminations	Termination Reason	Insert	New Registration			9/5/2019 12:52 PM