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CH042377D Northeast Florida Health Services Inc (Terminated)
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Main Details
Name
Northeast Florida Health Services Inc
Subdivision Name
Family Health Source Pediatric Clinic
Type
HRSA-Funded Health Center
Site ID
BPS-H80-019555
340B ID
CH042377D
Grant Number
H80CS02520
Additional Details
Current Program Status
Terminated
Registration Date
3/6/2018
Participating Start Date
4/1/2018
Participating Approval Date
3/6/2018
Last Recertification Date
2/3/2021
Termination Date
Termination Reason
10/1/2021
Business decision by the Covered Entity
Contacts
Authorizing Official
Northeast Florida Health Services, inc,
Laurie Asbury, CEO
(386) 624-1054
Primary Contact
Family Health Source
Hipolito Valdez, CFO
(386) 414-9601
Addresses
Street Address
800 West Plymouth Ave
Deland, FL 32720
Billing Address
Northeast Florida Health Services
1205 S Woodland Blvd
Suite 3
Deland, FL 32720
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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