Covered Entity Details

DSH100173B AdventHealth TAMPA (Active) - information as of 4/29/2025 11:52:28 PM

Main Details

Name

AdventHealth TAMPA

Subdivision Name

AdventHealth Kay Meyer Breast Care Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH100173B

Medicare Provider Number

100173

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/7/2019

Participating Start Date

1/1/2020

Participating Approval Date

10/31/2019

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

AdventHealth Tampa
Tyson Davis, Chief Financial Officer
(813) 615-7159

Primary Contact

AdventHealth Tampa
Rey Velez, 340B Program Coordinator
(813) 615-7244

Addresses

Street Address

3000 MEDICAL PARK DR
Suite 100
TAMPA, FL 33613

Billing Address

AdventHealth Tampa
c/o AdventHealth
902 inspiration Avenue
Suite 9100
Altamonte Springs, FL 32714

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	010102800	1053321919

Shipping Addresses

Shipping Address 1

AdventHealth Tampa
3100 East Fletcher Avenue
Tampa, FL 33613

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
DSH100173A	Child	DSH	AdventHealth TAMPA	AdventHealth Wound Care Center Tampa	3000 MEDICAL PARK Drive	TAMPA	FL	Active
DSH100173B	Child	DSH	AdventHealth TAMPA	AdventHealth Kay Meyer Breast Care Center	3000 MEDICAL PARK DR	TAMPA	FL	Active
DSH100173C	Child	DSH	AdventHealth TAMPA	AdventHealth Brandon ER	305 East Brandon Boulevard	Brandon	FL	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/14/2023 8:15:16 AM	8/14/2024 9:48:53 AM	8/14/2024 9:48 AM
Details	Last Recertification Date	Update	Recertification	9/14/2022 12:19:29 PM	8/14/2023 8:15:16 AM	8/14/2023 8:15 AM
Details	Last Recertification Date	Update	Recertification	8/19/2021 10:33:01 AM	9/14/2022 12:19:29 PM	9/14/2022 12:19 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	010102808 (FL)		3/13/2022 12:52 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	3/13/2022 12:52 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		010102800	3/13/2022 12:52 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	3/13/2022 12:52 PM
Details	Last Recertification Date	Update	Recertification	9/4/2020 9:38:42 AM	8/19/2021 10:33:01 AM	8/19/2021 10:33 AM
Details	Entity Subname	Update	Change Request	Kay Meyer Breast Care Center	AdventHealth Kay Meyer Breast Care Center	9/30/2020 7:01 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1053321919 ( )		9/4/2020 9:38 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1053321919	9/4/2020 9:38 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/4/2020 9:38 AM
Details	Last Recertification Date	Update	Recertification		9/4/2020 9:38:42 AM	9/4/2020 9:38 AM
Contacts	Authorizing Official	Update	Change Request	Coe, Jason Chief Operating Officer Advent Health Tampa 8136157129	Davis, Tyson Chief Financial Officer AdventHealth Tampa 8136157159	6/17/2020 10:57 AM
Contacts	Primary Contact	Update	Profile Change Request	Velez, Rey 340B Program Coordinator AdventHealth Tamnpa 8136157244	Velez, Rey 340B Program Coordinator AdventHealth Tampa 8136157244	4/7/2020 10:48 AM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	100173	010102808	11/19/2019 1:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1053321919	11/19/2019 1:13 PM
Details	Entity Subname	Update	Change Request	ADVENTHEALTH KAY MEYER BREAST CARE - AdventHealth Kay Meyer Breast Care	Kay Meyer Breast Care Center	11/19/2019 1:13 PM
Addresses	Main Address	Update	Change Request	3000 MEDICAL PARK DR STE 100 TAMPA, FL 33613-4691	3000 MEDICAL PARK DR Suite 100 TAMPA, FL 33613	11/6/2019 1:39 PM
Addresses	Shipping Address	Insert	Change Request		AdventHealth Tampa 3100 East Fletcher Avenue Tampa, FL 33613	11/6/2019 1:39 PM
Contacts	Signed By	Insert	New Registration		Coe, Jason Chief Operating Officer Advent Health Tampa 8136157129	10/31/2019 8:16 AM
Details	340B ID	Update	New Registration		DSH100173B	10/31/2019 8:16 AM
Details	Entity Name	Update	New Registration	ADVENTHEALTH TAMPA	AdventHealth TAMPA	10/31/2019 8:16 AM
Details	Entity Subname	Update	New Registration	ADVENTHEALTH KAY MEYER BREAST CARE	ADVENTHEALTH KAY MEYER BREAST CARE - AdventHealth Kay Meyer Breast Care	10/31/2019 8:16 AM
Dates	Participating Approval Date	Update	New Registration		10/31/2019 8:16:54 AM	10/31/2019 8:16 AM
Details	State	Update	New Registration	Pending	Approved	10/31/2019 8:16 AM
Dates	Signed By Date	Update	New Registration		10/7/2019 4:05:35 PM	10/31/2019 8:16 AM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	10/31/2019 8:16 AM
Contacts	Primary Contact	Update	Profile Change Request	Velez, Rey 340B Program Coordinator Florida Hospital Tampa 8136157244	Velez, Rey 340B Program Coordinator AdventHealth Tamnpa 8136157244	10/24/2019 5:04 AM
Addresses	Main Address	Insert	New Registration		3000 MEDICAL PARK DR STE 100 TAMPA, FL 33613-4691	10/7/2019 10:39 AM
Addresses	Billing Address	Insert	New Registration		AdventHealth Tampa c/o AdventHealth 902 inspiration Avenue Suite 9100 Altamonte Springs, FL 32714	10/7/2019 10:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/7/2019 10:39 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100173	10/7/2019 10:39 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	10/7/2019 10:39 AM
Contacts	Primary Contact	Insert	New Registration		Velez, Rey 340B Program Coordinator Florida Hospital Tampa 8136157244	10/7/2019 10:39 AM
Contacts	Authorizing Official	Insert	New Registration		Coe, Jason Chief Operating Officer Advent Health Tampa 8136157129	10/7/2019 10:39 AM
Details	Last Recertification Date	Insert	New Registration			10/7/2019 10:39 AM
Details	Grant Number	Insert	New Registration			10/7/2019 10:39 AM
Details	340B ID	Insert	New Registration			10/7/2019 10:39 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/7/2019 10:39 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/7/2019 10:39 AM
Details	Medicare Provider Number	Insert	New Registration		100173	10/7/2019 10:39 AM
Details	Entity Name	Insert	New Registration		ADVENTHEALTH TAMPA	10/7/2019 10:39 AM
Details	Program Code	Insert	New Registration		DSH	10/7/2019 10:39 AM
Details	Entity Subname	Insert	New Registration		ADVENTHEALTH KAY MEYER BREAST CARE	10/7/2019 10:39 AM
Dates	Participating Approval Date	Insert	New Registration			10/7/2019 10:39 AM
Details	State	Insert	New Registration		Pending	10/7/2019 10:39 AM
Dates	Registration Date	Insert	New Registration		10/7/2019 10:39:21 AM	10/7/2019 10:39 AM
Dates	Signed By Date	Insert	New Registration			10/7/2019 10:39 AM
Dates	Start Date	Insert	New Registration			10/7/2019 10:39 AM
Terminations	Termination Comments	Insert	New Registration			10/7/2019 10:39 AM
Terminations	Termination Date	Insert	New Registration			10/7/2019 10:39 AM
Terminations	Termination Effective Date	Insert	New Registration			10/7/2019 10:39 AM
Terminations	Termination Reason	Insert	New Registration			10/7/2019 10:39 AM