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DSH250019B MEMORIAL HOSPITAL AT GULFPORT (Active)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Memorial Allergy and Immunology Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019B
Medicare Provider Number
250019
Outpatient Facility Provider Number
700865
Additional Details
Current Program Status
Active
Registration Date
4/19/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/25/2012
Last Recertification Date
8/29/2024
Contacts
Authorizing Official
Memorial Hospital at Gulfport
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Primary Contact
Memorial Hospital at Gulfport
Brian Clark, Outpatient Pharmacy Director
(228) 867-4485
Addresses
Street Address
12261 Hwy 49 North, Suite 11
Gulfport, MS 39503
Billing Address
Memorial Hospital at Gulfport
4500 13th Street
Gulfport, MS 39501
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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