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BAYCARE HOME CARE INC
DSH100075A ST JOSEPH'S HOSPITAL
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Covered Entity Details
Entity Name
ST JOSEPH'S HOSPITAL
Subdivision Name
ST JOSEPH'S HOSPITAL- NORTH
Type
Disproportionate Share Hospital
340B ID
DSH100075A
Entity Address
4211 VAN DYKE ROAD
LUTZ, FL 33558
Medicare Provider Number
100075
Outpatient Facility Provider Number
Participating Start Date
4/1/2010
Last Recertification Date
8/31/2015
Entity Termination Date
4/1/2016
Pharmacy Details
Pharmacy Name
BAYCARE HOME CARE INC
Pharmacy Address
8452 118TH AVE N
LARGO, FL 33773-5007
Pharmacy Comments
Contract Details
Approval Date
7/9/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Carl Tremonti, Chief Financial Officer
(813) 870-4020
Contract Pharmacy Representative
Iqbal Burney, Director of Pharmacy
(727) 394-6577
Signed By Date
7/9/2015
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