BHCP / Phytogenics RX · Clinical Command Center & PECOS Dossier

Required Enrollment Attachment · First Coast Service Options, Inc. (JN)

Organizational Structure Diagram & Entity Disclosures

Reactivation of Deactivated Medicare Billing Number · Web Tracking ID: T101320260004770 · Date: 10/13/2026

PHYTOGENICS LLC

d/b/a Phytogenics Specialty Pharmacy

FEIN: 26-0826332 · NPI: 1356508980

PTAN: 7866660001 · Claims ID: NE526

FL DOH License: PH23251 (Exp: 02/28/2027)

I. Governance, Ownership & Operational Hierarchy Flowchart

100% Direct Owner · Authorized Official · Pharmacist-in-Charge

JOELLE M. MOLIERE, R.Ph.

5% or More Direct Owner (100% Equity) · Director / Officer · Managing Employee

FL Pharmacist Lic: PS 37743 (Active)

Role: RX DPT MGR / COR / POR

Effective Since: 09/01/2007

Phone: (754) 223-7701

100% Direct Ownership, Clinical Supervision & Legal Control

Applicant Entity · Medicare Part B / DMEPOS Enrolled Supplier

PHYTOGENICS LLC

d/b/a Phytogenics Specialty Pharmacy · Florida Proprietary LLC

TIN (FEIN): 26-0826332

Type 2 NPI: 1356508980

PTAN: 7866660001

FL Permit: PH23251

Medicaid ID: 103264100

Claims ID: NE526

Practice & Payment Address: 4501 NW 31st Ave, Oakland Park, FL 33309-3403

MSO & Contracted Billing (Sec. 8)

0% Equity Ownership · Contractual Claims & Administrative Support Only

BETTER HEALTH COMPOUNDING PHARMACIES LLC

TIN: 42-2639055 · Eff: 10/13/2026 (Added)

303B Anastasia Blvd, St. Augustine, FL 32080

Role: MSO Platform & Contracted Billing Agent (Fixed FMV MSA; never bills Medicare directly)

THE OLIVIA EFFECT LLC

TIN: 84-3110791 · Eff: 12/10/2020

1300 E Hillsboro Blvd, Ste 201-B, Deerfield Bch, FL

INTELIBILL PROFESSIONAL SERVICES LLC

TIN: 83-2768245 · Eff: 03/05/2026

5379 Lyons Rd #153, Coconut Creek, FL 33073

Delegated Officials & Contacts

0% Equity Ownership · Administrative PECOS Filing Authority

PAUL KELSO SMITH

Delegated Official & Submitter · Added 10/13/2026

208 Oklahoma Ave, Satsuma, FL 32189

paul.smith@bhg.llc · (904) 990-4363

OLIVIA H. ACOSTA

Deleted / Terminated Effective: 02/05/2025

Former Delegated Official & Managing Employee role ended in Section 6 & Section 13.

CLINICAL PRESCRIBING INTERFACE

Independent telehealth evaluations originate via licensed practitioners (Better Health Medical PA · NPI 1487920112). Zero physician ownership in pharmacy.

Depository, Bond & Fulfillment

0% Equity Ownership · Statutory Financial & Supply Contracts

JPMORGAN CHASE BANK, N.A.

CMS-588 EFT Depository · Routing: XXXXX4131

Account: XXXXXXXXXXXXX6075 (Checking)

1319 S State Rd 7, North Lauderdale, FL 33068

SCOTTSDALE INSURANCE CO.

CGL Policy: CPS4119024 ($1M / $3M Agg)

Term: 07/08/2026 to 07/08/2027

UNIVERSAL FIRE & CASUALTY INS.

DMEPOS Surety Bond #10002261 ($50,000)

AMRAN MEDICAL PRODUCTS

Contracted DMEPOS Orthoses Fulfillment & Executed BAA (Uploaded 03/17/2026)

II. Complete Entity & Individual Relationship Disclosure Matrix

Entity / Individual Name	Identifiers (TIN / NPI / Lic)	PECOS Classification	Ownership	Relationship to Phytogenics LLC & Inter-Entity Structure
PHYTOGENICS LLC d/b/a Phytogenics Specialty Pharmacy	TIN: 26-0826332 NPI: 1356508980 PTAN: 7866660001 FL Lic: PH23251	Applicant / Enrolled Supplier	Primary Entity	Licensed Florida Schedule II & III Community Pharmacy and Medicare Part B / DMEPOS supplier located at 4501 NW 31st Ave, Oakland Park, FL 33309.
JOELLE M. MOLIERE, R.Ph. Prescription Dept. Manager	FL Lic: PS 37743 NPI: 1346547346 SSN: On File (Sec. 6)	Direct Owner · Director · Authorized Official · Managing Employee	100% Direct	Sole 100% Direct Owner ("5% or More Direct Owner" active since 09/01/2007; combined Direct/Indirect line item closed 10/13/2026 to isolate 100% Direct status), President/Director, Pharmacist-in-Charge, and primary Authorized Official.
BETTER HEALTH COMPOUNDING PHARMACIES LLC	TIN: 42-2639055 NPI: 1841125655 St. Augustine, FL	Billing Agency / MSO (Sec. 8 · Added 10/13/2026)	0%	Administrative MSO and contracted third-party billing agency. Operates under fixed FMV Management Services Agreement; holds zero ownership in Phytogenics LLC and never bills Medicare in its own name.
PAUL KELSO SMITH	Satsuma, FL paul.smith@bhg.llc (904) 990-4363	Delegated Official & Application Contact (Added 10/13/2026)	0%	Designated Delegated Official and enrollment contact person authorized by Joelle M. Moliere to submit PECOS enrollment reactivations and updates. Affiliated with Better Health Compounding Pharmacies LLC.
THE OLIVIA EFFECT LLC	TIN: 84-3110791 Deerfield Beach, FL	Billing Agency (Sec. 8 · Eff. 12/10/2020)	0%	Independent third-party billing vendor contracted for claims processing. No ownership or managerial authority over the applicant.
INTELIBILL PROFESSIONAL SERVICES LLC	TIN: 83-2768245 Coconut Creek, FL	Billing Agency (Sec. 8 · Eff. 03/05/2026)	0%	Independent third-party revenue cycle and electronic billing vendor on file in PECOS. Zero equity or governance control.
OLIVIA H. ACOSTA	Deleted 02/05/2025	Former Delegated Official (Removed)	0%	All Delegated Official, Managing Employee, and Contact Person privileges terminated effective 02/05/2025.
AMRAN MEDICAL PRODUCTS DMEPOS Supply Partner	Contract & BAA Uploaded 03/17/2026	Contracted DMEPOS Fulfillment Vendor	0%	Furnishes off-the-shelf orthoses and DME items per executed Supplier Agreement and HIPAA Business Associate Agreement.
JPMORGAN CHASE BANK, N.A. SCOTTSDALE INS. CO. UNIVERSAL FIRE & CASUALTY	Acct: ...6075 Pol: CPS4119024 Bond: #10002261	CMS-588 Depository · Liability Carrier · Surety Underwriter	0%	Institutional banking depository for EFT claim payments, $1M/$3M Commercial General Liability insurer (07/08/2026–07/08/2027), and $50,000 DMEPOS surety bond issuer.

Statutory Certification & Ownership Attestation (42 C.F.R. § 424.57 / CMS-855B & CMS-855S):

I hereby certify under penalty of perjury that the organizational structure diagram and entity relationship disclosures set forth herein accurately and completely identify PHYTOGENICS LLC (FEIN 26-0826332, NPI 1356508980, PTAN 7866660001) and all individuals and organizations maintaining ownership interest, managing control, delegated signing authority, or third-party billing contracts under PECOS Web Tracking ID T101320260004770. No undisclosed person or entity holds a 5% or greater direct or indirect ownership or controlling interest.

Authorized Official Signature

Joelle M. Moliere, R.Ph.

JOELLE M. MOLIERE · 100% Direct Owner / Director / Authorized Official

FL Pharmacist License: PS 37743 · Phone: (754) 223-7701

Delegated Official & Date of Filing

October 13, 2026 · Tracking ID: T101320260004770

Submitted By: PAUL KELSO SMITH (Delegated Official)

Practice Location: 4501 NW 31st Ave, Oakland Park, FL 33309-3403

15-Calendar-Day MAC Submission Window Active

Application T101320260004770 was transmitted on October 13, 2026 at 04:17:20 PM EST by Paul Smith. All e-signatures, wet-ink agreements, and non-uploaded supporting documents must be received by First Coast Service Options, Inc. (JN) no later than Wednesday, October 28, 2026.

Statutory Deadline

2026-10-28 · 17:00 EST

Assigned Medicare Contractor

FIRST COAST SERVICE OPTIONS, INC.

JN Medicare Provider Enrollment

FIRST COAST SERVICE OPTIONS, INC.
JN MEDICARE PROVIDER ENROLLMENT
P.O. BOX 3409
MECHANICSBURG, PA 17055-1849

Include the Submission Confirmation receipt and Tracking ID T101320260004770 on the cover sheet of any physical mail packet.

Section 6 Ownership Audit Flag

On Page 3 of the 10/13/2026 PECOS report, Joelle M. Moliere's role "5% OR GREATER DIRECT/INDIRECT OWNER" displays an End Date of 10/13/2026, while "5% OR MORE DIRECT OWNER" remains open/active (Effective 12/10/2020).

Clinical / Legal Action: Ensure the uploaded Organizational Structure Diagram (View 1) and IRS LTR 147C (`PhytogenicsFEINlett.pdf`) accompany the file so the First Coast examiner sees uninterrupted 100% direct ownership.

Verified Source Files On Hand

FL DOH Pharmacy PH23251 Exp 02/28/2027

FL Pharmacist PS 37743 Exp 09/30/2027

Scottsdale CGL CPS4119024 Exp 07/08/2027

IRS EIN 26-0826332 LTR 147C Verified

Form CMS-460 (NPI 1356508980) Verify Sign Date

Part A · Mandatory Certification Statements (E-Sign or Upload)

PIN & Web Tracking ID T101320260004770 dispatched via customerservice-donotreply@cms.hhs.gov

0 / 2 Signed

1. Authorized Official Certification Statement for Clinics and Group Practices [PDF] Signer: JOELLE M. MOLIERE

Sent to phytogenix@gmail.com. Joelle must authenticate with the PECOS PIN and execute the electronic signature, or print the certification PDF, sign in wet ink, and upload via My Enrollments → Manage Signatures.

2. Delegated Official Certification Statement for Clinics and Group Practices [PDF] Signer: PAUL KELSO SMITH

Sent to paul.smith@bhg.llc. Required because Paul Kelso Smith was added as Delegated Official on 10/13/2026. Note: Section 6 must reflect W-2 Managing Employee or ownership/control status per CMS-855 rules.

Part B · Required & Supporting Documents Packet (Page 5 of Report)

Note from Submission Confirmation: Documents marked Unspecified cannot be uploaded post-submission and must be mailed to Mechanicsburg, PA within 15 days.

0 / 6 Prepared

3. Copy of an Organizational Structure Diagram / Flowchart Delivery: UPLOAD · Ready in View 1

Switch to View 1 (Organizational Structure Diagram) above and click Save as PDF to generate the clean 8.5" x 11" attachment identifying Joelle Moliere, Phytogenics LLC, Better Health Compounding Pharmacies LLC, The Olivia Effect LLC, Intelibill, and Paul Kelso Smith.

4. Form CMS-460: Medicare Participating Physician or Supplier Agreement Delivery: UNSPECIFIED (Mail to JN)

On hand (`MEDICARE PARTICIPATING SUPPLIER AGREEMENT.pdf`, signed 09/10/2019). Audit Check: Page 1 of the 2019 PDF has a typo in the NPI field (`1356506980` instead of `1356508980`). Print a fresh CMS-460 with NPI 1356508980 signed by Joelle Moliere for the First Coast mail packet.

5. Voided Check or Letter from Bank Confirming Account Information Delivery: UNSPECIFIED (Mail to JN)

Must match CMS-588 Section: Chase Bank (1319 S State Rd 7, North Lauderdale, FL 33068 · Tel: 954-974-0324), Routing XXXXX4131, Checking Account XXXXXXXXXXXXX6075, Account Holder: PHYTOGENICS LLC.

6. Form CMS-588: Electronic Funds Transfer (EFT) Authorization Agreement Delivery: MAIL / UPLOAD

Include executed CMS-588 signed by Joelle Moliere (Director/President) paired with the Chase Bank voided check or bank letterhead verification.

7. Copy of Business Licenses, Certifications, Liability Policy & IRS LTR 147C Files Verified in Dossier

Enclose: (a) FL DOH MQA Pharmacy Verification PH23251 (as of 10/13/2026, exp 02/28/2027), (b) Pharmacist License PS 37743 (exp 09/30/2027), (c) Scottsdale Insurance CGL Policy CPS4119024 (07/08/2026–07/08/2027), and (d) IRS FEIN Letter 26-0826332.

8. Other Documentation Requested by Medicare Contractor Delivery: UPLOAD / MAIL

Include executed Billing Agency/MSA agreements with Better Health Compounding Pharmacies LLC and The Olivia Effect LLC, plus the Amran Medical Products Supplier Agreement & BAA.

Every status change is recorded in the HIPAA Session Audit Ledger.

Three-Entity Legal & Statutory Separation Architecture

Enforced across all PECOS filings, e-prescribing payloads, and claims adjudication workflows to maintain False Claims Act (31 U.S.C. § 3729) and Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) compliance.

1. MSO / Tech Platform

Better Health Compounding Pharmacies LLC

FEIN: 42-2639055 · NPI: 1841125655
Taxonomy: 246Y00000X

Collects fixed Fair Market Value (FMV) monthly fee via Management Services Agreement (MSA). Listed in PECOS Section 8 strictly as administrative Billing Agent. Never bills Medicare directly.

2. Medical Group PA

Better Health Medical PA

Type 2 Group NPI: 1487920112
PTAN: FL892019 (PECOS)

Independent clinical telehealth consultations and diagnostic evaluations. Generates Letters of Medical Necessity (LMN) when step-therapy fails. No direct dispensing.

3. 503A / DMEPOS Dispensing Lab

Phytogenics LLC (Phytogenics RX)

FEIN: 26-0826332 · FL Lic: PH23251
Part B NPI: 1356508980 · PTAN: 7866660001
Part D Lab NPI: 1003491689 · NCPDP: 1098421

100% owned by Joelle M. Moliere, R.Ph. (PS 37743). Executes all Section 503A compounding, DMEPOS fulfillment, and NCPDP D.0 / Part B claims transmission.

NCPDP Version D.0 Mandatory Header & DUR Spec

Field 406-D6 = "2" // Compound Code

Field 436-E1 = "00" // Multi-Ingredient Qualifier

Field 407-D7 = "00000000000" // 11 Zeroes Mandatory

Field 420-DK = "08" // Process Approved Ingredients

Field 461-EU = "0" | "1" // Prior Auth / LMN Override

Field 405-D5 = "30" // Strict 30-Day Supply Cap

Field 442-E7 = "60.000" | "120.000" // Max 4.0 g/day

100% Commercial NDC & Dilution Label SOP

Zero Bulk API Powders (42 CFR § 423.100): Only finished commercial manufacturer packages (McKesson, Cardinal, Cencora) matching billed NDCs in Field 489-TE are dispensed.
50/50 Blending Concentration Halving:
60g Lidocaine 5% + 60g Doxepin 5% (120g Total)
→ Label: "Lidocaine 2.5% / Doxepin 2.5% Topical Cream"

60g Lidocaine 5% + 60g Diclofenac 3% (120g Total)
→ Label: "Lidocaine 2.5% / Diclofenac Sodium 1.5% Topical Gel"
IRA Catastrophic POS Threshold: Sub-$850 Default Tier ($765–$795 AWP) clears automated POS edits; High-Yield Elevated Tier ($945–$2,225+ AWP) resolves Reject Code 75 via pre-signed LMN.