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DSH250019BQ MEMORIAL HOSPITAL AT GULFPORT (Approved)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Diamondhead Clinic-Urology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019BQ
Medicare Provider Number
250019
Outpatient Facility Provider Number
250019
Additional Details
Current Program Status
Approved
Registration Date
4/4/2025
Participating Start Date
7/1/2025
Participating Approval Date
4/17/2025
Last Recertification Date
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
4300 Leisure Time Drive
Diamondhead, MS 39525
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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Participated starting 10/1/2014, terminated 1/1/2022. Reinstated 7/1/2025.
04/16/2025
April 2025
April 2025
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