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BRIOVARX OF FLORIDA, INC
DSH100088 BAPTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
BAPTIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100088
Entity Address
800 PRUDENTIAL DRIVE
JACKSONVILLE, FL 32207
Medicare Provider Number
100088
Participating Start Date
7/1/2006
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF FLORIDA, INC
Pharmacy Address
D/B/A BRIOVARX OF FLORIDA
9994 PREMIER PKWY
MIRAMAR, FL 33025
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/13/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Scott M. Wooten, SVP & CFO
(904) 202-3405
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/12/2019
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