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DSH250019BB MEMORIAL HOSPITAL AT GULFPORT (Terminated)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Memorial Internal Medicine- Drinkwater- Family Practice
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019BB
Medicare Provider Number
250019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/10/2014
Participating Start Date
7/1/2014
Participating Approval Date
6/11/2014
Last Recertification Date
8/29/2022
Termination Date
Termination Reason
7/1/2023
Business decision by the Covered Entity
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
300 Drinkwater Drive
Bay St Louis, MS 39520
Billing Address
Memorial Hospital at Gulfport
4500 Thirteenth Street
Gulfport, MS 39501
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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