| Contacts | Primary Contact | Update | Profile Change Request | Abrams, Ely S
340b Coordinator
AdventHealth
8634192511 | Abrams, Ely S
340b Coordinator
AdventHealth
4077709259 | 1/2/2025 10:00 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Abrams, Ely S
Buyer
AdventHealth
8634192511 | Abrams, Ely S
340b Coordinator
AdventHealth
8634192511 | 1/2/2025 9:59 AM |
| Addresses | Shipping Address | Delete | Recertification | AdventHealth Heart of Flordia
40100 US HWY 27
Davenport, FL 33837 | | 8/23/2024 11:14 AM |
| Addresses | Shipping Address | Insert | Recertification | | AdventHealth Heart of Florida
40100 US HWY 27
Davenport, FL 33837 | 8/23/2024 11:14 AM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2023 2:35:18 PM | 8/23/2024 11:14:20 AM | 8/23/2024 11:14 AM |
| Details | Last Recertification Date | Update | Recertification | 9/16/2022 2:34:50 PM | 8/28/2023 2:35:18 PM | 8/28/2023 2:35 PM |
| Addresses | Billing Address | Update | Change Request | AdventHealth
902 Inspiration Ave
Suite 9100
Altamonte Springs, FL 32714 | AdventHealth Heart of Florida
c/o AdventHealth
902 Inspiration Ave
Suite 9100
Altamonte Springs, FL 32714 | 8/10/2023 11:40 AM |
| Addresses | Shipping Address | Update | Change Request | ADVENTHEALTH WOUND CARE HAINES CITY
280 PATTERSON RD
HAINES CITY, FL 32714 | ADVENTHEALTH WOUND CARE HAINES CITY
280 PATTERSON RD
HAINES CITY, FL 33844 | 8/10/2023 11:40 AM |
| Contacts | Authorizing Official | Update | AO Change Request | Harmeling, Kami Mitchell
Assistant Chief Financial Officer
AdventHealth Polk North, Inc.
8634191830 | Hengesbach, Alan
CFO
AdventHealth Heart of Florida
3524006221 | 2/21/2023 9:26 AM |
| Details | Last Recertification Date | Update | Recertification | 9/15/2021 7:58:34 AM | 9/16/2022 2:34:50 PM | 9/16/2022 2:34 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Heinrich, William Keith
CFO
AdventHealth Heart of Florida
8634192260 | Harmeling, Kami Mitchell
Assistant Chief Financial Officer
AdventHealth Polk North, Inc.
8634191830 | 9/17/2021 12:57 PM |
| Addresses | Shipping Address | Insert | Recertification | | ADVENTHEALTH WOUND CARE HAINES CITY
280 PATTERSON RD
HAINES CITY, FL 32714 | 9/15/2021 7:58 AM |
| Addresses | Shipping Address | Insert | Recertification | | AdventHealth Heart of Flordia
40100 US HWY 27
Davenport, FL 33837 | 9/15/2021 7:58 AM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2020 11:10:58 AM | 9/15/2021 7:58:34 AM | 9/15/2021 7:58 AM |
| Details | Entity Name | Update | Change Request | HEART OF FLORIDA REGIONAL MEDICAL CE | AdventHealth Heart of Florida | 8/13/2021 9:34 AM |
| Details | Entity Subname | Update | Change Request | ADVENTHEALTH WOUND CARE HAINES CITY - Wound Care and Hyperbaric Oxygen | ADVENTHEALTH WOUND CARE HAINES CITY | 8/13/2021 9:33 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 9/9/2020 11:10 AM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 010228800 | 9/9/2020 11:10 AM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | FL | 9/9/2020 11:10 AM |
| Medicaid Billing | NPI: State | Update | Recertification | | FL | 9/9/2020 11:10 AM |
| Contacts | Primary Contact | Update | Recertification | gillilan, cindy lynn
pharmacy buyer
adventhealth heart of florida
8634192511 | Abrams, Ely S
Buyer
AdventHealth
8634192511 | 9/9/2020 11:10 AM |
| Details | Last Recertification Date | Update | Recertification | | 9/9/2020 11:10:58 AM | 9/9/2020 11:10 AM |
| Details | State | Update | | Approved | Active | 7/1/2020 12:00 AM |
| Details | 340B ID | Update | OPA Edit | RRC33837-01 | RRC100137-01 | 6/11/2020 8:40 AM |
| Contacts | Signed By | Insert | New Registration | | Heinrich, William Keith
CFO
AdventHealth Heart of Florida
8634192260 | 6/2/2020 3:40 PM |
| Details | 340B ID | Update | New Registration | | RRC33837-01 | 6/2/2020 3:40 PM |
| Details | Entity Subname | Update | New Registration | ADVENTHEALTH WOUND CARE HAINES CITY | ADVENTHEALTH WOUND CARE HAINES CITY - Wound Care and Hyperbaric Oxygen | 6/2/2020 3:40 PM |
| Dates | Participating Approval Date | Update | New Registration | | 6/2/2020 3:40:51 PM | 6/2/2020 3:40 PM |
| Details | State | Update | New Registration | Pending | Approved | 6/2/2020 3:40 PM |
| Dates | Signed By Date | Update | New Registration | | 4/7/2020 4:58:48 PM | 6/2/2020 3:40 PM |
| Dates | Start Date | Update | New Registration | | 7/1/2020 12:00:00 AM | 6/2/2020 3:40 PM |
| Addresses | Main Address | Insert | New Registration | |
280 PATTERSON RD
STE 4
HAINES CITY, FL 33844-6261 | 4/6/2020 10:44 AM |
| Addresses | Billing Address | Insert | New Registration | | AdventHealth
902 Inspiration Ave
Suite 9100
Altamonte Springs, FL 32714 | 4/6/2020 10:44 AM |
| Medicaid Billing | NPI: Number | Insert | New Registration | | 1801457510 | 4/6/2020 10:44 AM |
| Contacts | Authorizing Official | Insert | New Registration | | Heinrich, William Keith
CFO
AdventHealth Heart of Florida
8634192260 | 4/6/2020 10:44 AM |
| Contacts | Primary Contact | Insert | New Registration | | gillilan, cindy lynn
pharmacy buyer
adventhealth heart of florida
8634192511 | 4/6/2020 10:44 AM |
| Details | Last Recertification Date | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Details | Grant Number | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Details | 340B ID | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Details | Is Authorizing Official EHB Data | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Details | Medicare Provider Number | Insert | New Registration | | 100137 | 4/6/2020 10:44 AM |
| Details | Entity Name | Insert | New Registration | | HEART OF FLORIDA REGIONAL MEDICAL CE | 4/6/2020 10:44 AM |
| Details | Program Code | Insert | New Registration | | RRC | 4/6/2020 10:44 AM |
| Details | Entity Subname | Insert | New Registration | | ADVENTHEALTH WOUND CARE HAINES CITY | 4/6/2020 10:44 AM |
| Dates | Participating Approval Date | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Details | State | Insert | New Registration | | Pending | 4/6/2020 10:44 AM |
| Dates | Registration Date | Insert | New Registration | | 4/6/2020 10:44:34 AM | 4/6/2020 10:44 AM |
| Dates | Signed By Date | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Dates | Start Date | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Terminations | Termination Comments | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Terminations | Termination Date | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Terminations | Termination Effective Date | Insert | New Registration | | | 4/6/2020 10:44 AM |
| Terminations | Termination Reason | Insert | New Registration | | | 4/6/2020 10:44 AM |