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  5. MAGNOLIA MEDICAL CLINIC, P.A.

MAGNOLIA MEDICAL CLINIC, P.A.

Company Details

Entity Name: MAGNOLIA MEDICAL CLINIC, P.A.
Jurisdiction: FLORIDA
Filing Type: Domestic Profit
Status: Active
Date Filed: 12 Jun 1995 (30 years ago)
Last Event: REINSTATEMENT
Event Date Filed: 15 Apr 2019 (6 years ago)
Document Number: P95000046696
FEI/EIN Number 593322674
Address: 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547, US
Mail Address: 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547, US
ZIP code: 32547
County: Okaloosa
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1639281652 2006-08-31 2024-07-15 319 GREEN ACRES RD STE 101, FORT WALTON BEACH, FL, 325471170, US 319 GREEN ACRES RD STE 101, FORT WALTON BEACH, FL, 32547, US

Contacts
Phone +1 850-243-7681
Fax 8502430471

Authorized person
Name MRS. CRYSTAL WEATHERINGTON
Role PRACTICE ADMINISTRATOR
Phone 8502430520

Taxonomy
Taxonomy Code 207Q00000X - Family Medicine Physician
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 254841100
State FL
Issuer RAIL ROAD
Number CH5541
State FL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2023 593322674 2024-07-12 MAGNOLIA MEDICAL CLINIC, P.A. 40
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 319 GREEN ACRES RD, SUITE 101, FORT WALTON BEACH, FL, 32547

Signature of
Role Plan administrator
Date 2024-07-12
Name of individual signing CHRIS G. PAPPAS, MD
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2022 593322674 2023-07-13 MAGNOLIA MEDICAL CLINIC, P.A. 39
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 319 GREEN ACRES RD, SUITE 101, FORT WALTON BEACH, FL, 32547

Signature of
Role Plan administrator
Date 2023-07-13
Name of individual signing CHRIS G. PAPPAS, MD
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2021 593322674 2022-10-12 MAGNOLIA MEDICAL CLINIC, P.A. 38
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 319 GREEN ACRES RD, SUITE 101, FORT WALTON BEACH, FL, 32547

Signature of
Role Plan administrator
Date 2022-10-12
Name of individual signing CHRIS G. PAPPAS, MD
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2020 593322674 2021-10-15 MAGNOLIA MEDICAL CLINIC, P.A. 36
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 319 GREEN ACRES ROAD, SUITE 101, FORT WALTON BEACH, FL, 32547

Signature of
Role Plan administrator
Date 2021-10-15
Name of individual signing JOHN D. SITES, M.D.
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2019 593322674 2020-10-12 MAGNOLIA MEDICAL CLINIC, P.A. 36
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 319 GREEN ACRES ROAD, SUITE 101, FORT WALTON BEACH, FL, 32547

Signature of
Role Plan administrator
Date 2020-10-12
Name of individual signing JOHN D. SITES, M.D.
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2018 593322674 2019-07-12 MAGNOLIA MEDICAL CLINIC, P.A. 31
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 319 GREEN ACRES ROAD, SUITE 101, FORT WALTON BEACH, FL, 32547

Signature of
Role Plan administrator
Date 2019-07-12
Name of individual signing JOHN D. SITES, M.D.
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2017 593322674 2018-10-12 MAGNOLIA MEDICAL CLINIC, P.A. 29
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 319 GREEN ACRES ROAD, SUITE 101, FORT WALTON BEACH, FL, 32547

Signature of
Role Plan administrator
Date 2018-10-12
Name of individual signing JOHN D. SITES, M.D.
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2016 593322674 2017-12-14 MAGNOLIA MEDICAL CLINIC, P.A. 29
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 319 GREEN ACRES ROAD, SUITE 101, FORT WALTON BEACH, FL, 32547

Signature of
Role Plan administrator
Date 2017-12-14
Name of individual signing JOHN D. SITES, M.D.
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2015 593322674 2016-10-14 MAGNOLIA MEDICAL CLINIC, P.A. 28
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 131 MAGNOLIA AVE., S.E., FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2016-10-14
Name of individual signing JOHN D. SITES, M.D.
Valid signature Filed with authorized/valid electronic signature
MAGNOLIA MEDICAL CLINIC, P.A. PROFIT SHARING PLAN 2014 593322674 2015-03-25 MAGNOLIA MEDICAL CLINIC, P.A. 29
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1995-07-01
Business code 621111
Sponsor’s telephone number 8502437681
Plan sponsor’s address 131 MAGNOLIA AVE., S.E., FORT WALTON BEACH, FL, 32548

Signature of
Role Plan administrator
Date 2015-03-25
Name of individual signing JOHN D. SITES, M.D.
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
Loudermilk John Dr. Agent 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547

Treasurer

Name Role Address
Pappas Chris GDr. Treasurer 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547

Director

Name Role Address
Paulson Christopher PDr. Director 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547
Skojac Teresa MDr. Director 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547
Zachary III Grant EDr. Director 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547

President

Name Role Address
Loudermilk John President 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547

Vice President

Name Role Address
McDevitt Emily G Vice President 319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547

Events

Event Type Filed Date Value Description
REGISTERED AGENT NAME CHANGED 2025-01-28 McDevitt, Emily C, Dr. No data
REINSTATEMENT 2019-04-15 No data No data
REGISTERED AGENT ADDRESS CHANGED 2019-04-15 319 GREEN ACRES ROAD, SUITE 101, FORT WALTON BEACH, FL 32547 No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2018-09-28 No data No data
CHANGE OF PRINCIPAL ADDRESS 2017-08-28 319 GREEN ACRES ROAD, SUITE 101, FORT WALTON BEACH, FL 32547 No data
CHANGE OF MAILING ADDRESS 2017-08-28 319 GREEN ACRES ROAD, SUITE 101, FORT WALTON BEACH, FL 32547 No data

Documents

Name Date
ANNUAL REPORT 2025-01-28
ANNUAL REPORT 2024-02-07
ANNUAL REPORT 2023-01-27
ANNUAL REPORT 2022-01-26
ANNUAL REPORT 2021-03-25
AMENDED ANNUAL REPORT 2020-09-08
ANNUAL REPORT 2020-01-29
REINSTATEMENT 2019-04-15
ANNUAL REPORT 2017-01-13
ANNUAL REPORT 2016-04-15

Related by officers

Loudermilk John

ADVANCE ARBOR PROFESSIONAL CARE, LLC

Related by address

319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547, US

CENTURION GROUP LIMITED, PLLC

319 GREEN ACRES ROAD, FORT WALTON BEACH, FL, 32547, US

CENTURION GROUP LIMITED, PLLC

Date of last update: 02 Feb 2025

Sources: Florida Department of State

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