Covered Entity Details

DSH450152F AdventHealth Central Texas (Active) - information as of 6/12/2025 6:07:54 AM

Main Details

Name

AdventHealth Central Texas

Subdivision Name

ADVENTHEALTH MEDICAL GROUP PSYCHIAT - AdventHealth Medical Group Psychiatry & Psychology at Killeen

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450152F

Medicare Provider Number

450152

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/5/2020

Participating Start Date

1/1/2021

Participating Approval Date

10/15/2020

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

AdventHealth Central Texas
Janet Garcia, Chief Financial Officer
(682) 459-7140

Primary Contact

AdventHealth
Dustin Lott Jones, 340B Coordinator
(254) 833-1495

Addresses

Street Address

2407 S CLEAR CREEK RD
BLDG A, STE 11, 12, 17, 18, 19
KILLEEN, TX 76549-7521

Billing Address

AdventHealth Central Texas
c/o AdventHealth
902 Inspiration Ave
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
TX	094119702	1629089966

Shipping Addresses

Shipping Address 1

AdventHealth Central Texas
2201 S. Clear Creek Rd
Killeen, TX 76549

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
DSH450152A	Child	DSH	AdventHealth Central Texas	AdventHealth Imaging Harker Heights	5610 E Central Texas Expressway	Killeen	TX	Active
DSH450152B	Child	DSH	AdventHealth Central Texas	AdventHealth Wound Care Killeen	2300 S Clear Creek Rd	Killeen	TX	Active
DSH450152C	Child	DSH	AdventHealth Central Texas	AdventHealth Behavioral Health Center	2407 South Clear Creek Rd	Killeen	TX	Active
DSH450152D	Child	DSH	METROPLEX HOSPITAL	Metroplex Home Health Agency	2115 S. Clear Creek Rd.	Killeen	TX	Terminated
DSH450152E	Child	DSH	AdventHealth Central Texas	AdventHealth Wound Care Center Harker Heights	5610 East Central Texas Expressway	Killeen	TX	Active
DSH450152F	Child	DSH	AdventHealth Central Texas	ADVENTHEALTH MEDICAL GROUP PSYCHIAT - AdventHealth Medical Group Psychiatry & Psychology at Killeen	2407 S CLEAR CREEK RD	KILLEEN	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	PC Change Request	King, Jerry F Director of Pharmacy AdventHealth Central Texas, AdventHealth Rollins Brook 2545198282	Jones, Dustin Lott 340B Coordinator AdventHealth 2548331495	3/26/2025 6:17 AM
Details	Last Recertification Date	Update	Recertification	9/6/2023 8:15:37 PM	9/4/2024 5:26:32 PM	9/4/2024 5:26 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 12:26:49 PM	9/6/2023 8:15:37 PM	9/6/2023 8:15 PM
Contacts	Authorizing Official	Update	Change Request	Pridgen, Parker COO/CFO AdventHealth Central Texas 2545198165	Garcia, Janet Chief Financial Officer AdventHealth Central Texas 6824597140	7/26/2023 5:58 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 9:22:22 AM	9/6/2022 12:26:49 PM	9/6/2022 12:26 PM
Details	Last Recertification Date	Update	Recertification		9/7/2021 9:22:22 AM	9/7/2021 9:22 AM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Pridgen, Parker COO/CFO AdventHealth Central Texas 2545198165	10/15/2020 7:30 AM
Details	340B ID	Update	New Registration		DSH450152F	10/15/2020 7:30 AM
Details	Entity Subname	Update	New Registration	ADVENTHEALTH MEDICAL GROUP PSYCHIAT	ADVENTHEALTH MEDICAL GROUP PSYCHIAT - AdventHealth Medical Group Psychiatry & Psychology at Killeen	10/15/2020 7:30 AM
Dates	Participating Approval Date	Update	New Registration		10/15/2020 7:30:33 AM	10/15/2020 7:30 AM
Details	State	Update	New Registration	Pending	Approved	10/15/2020 7:30 AM
Dates	Signed By Date	Update	New Registration		10/12/2020 9:58:40 AM	10/15/2020 7:30 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	10/15/2020 7:30 AM
Addresses	Main Address	Insert	New Registration		2407 S CLEAR CREEK RD BLDG A, STE 11, 12, 17, 18, 19 KILLEEN, TX 76549-7521	10/5/2020 4:53 PM
Addresses	Billing Address	Insert	New Registration		AdventHealth Central Texas c/o AdventHealth 902 Inspiration Ave Suite 9100 Altamonte Springs, FL 32714	10/5/2020 4:53 PM
Addresses	Shipping Address	Insert	New Registration		AdventHealth Central Texas 2201 S. Clear Creek Rd Killeen, TX 76549	10/5/2020 4:53 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/5/2020 4:53 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		094119702	10/5/2020 4:53 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	10/5/2020 4:53 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1629089966	10/5/2020 4:53 PM
Medicaid Billing	NPI: State	Insert	New Registration		TX	10/5/2020 4:53 PM
Contacts	Authorizing Official	Insert	New Registration		Pridgen, Parker COO/CFO AdventHealth Central Texas 2545198165	10/5/2020 4:53 PM
Contacts	Primary Contact	Insert	New Registration		King, Jerry F Director of Pharmacy AdventHealth Central Texas, AdventHealth Rollins Brook 2545198282	10/5/2020 4:53 PM
Details	Assistance Received From Date	Insert	New Registration			10/5/2020 4:53 PM
Details	Assistance Received To Date	Insert	New Registration			10/5/2020 4:53 PM
Details	Last Recertification Date	Insert	New Registration			10/5/2020 4:53 PM
Details	Grant Number	Insert	New Registration			10/5/2020 4:53 PM
Details	340B ID	Insert	New Registration			10/5/2020 4:53 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/5/2020 4:53 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/5/2020 4:53 PM
Details	Medicare Provider Number	Insert	New Registration		450152	10/5/2020 4:53 PM
Details	Entity Name	Insert	New Registration		AdventHealth Central Texas	10/5/2020 4:53 PM
Details	NOFO Number	Insert	New Registration			10/5/2020 4:53 PM
Details	Program Code	Insert	New Registration		DSH	10/5/2020 4:53 PM
Details	Entity Subname	Insert	New Registration		ADVENTHEALTH MEDICAL GROUP PSYCHIAT	10/5/2020 4:53 PM
Dates	Participating Approval Date	Insert	New Registration			10/5/2020 4:53 PM
Details	State	Insert	New Registration		Pending	10/5/2020 4:53 PM
Dates	Registration Date	Insert	New Registration		10/5/2020 4:53:57 PM	10/5/2020 4:53 PM
Dates	Signed By Date	Insert	New Registration			10/5/2020 4:53 PM
Dates	Start Date	Insert	New Registration			10/5/2020 4:53 PM
Terminations	Termination Comments	Insert	New Registration			10/5/2020 4:53 PM
Terminations	Termination Date	Insert	New Registration			10/5/2020 4:53 PM
Terminations	Termination Effective Date	Insert	New Registration			10/5/2020 4:53 PM
Terminations	Termination Reason	Insert	New Registration			10/5/2020 4:53 PM