340B Drug Pricing Program Database
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DSH250019FK MEMORIAL HOSPITAL AT GULFPORT (Terminated)
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Main Details
Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Acadian Plaza- Endocrinology
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH250019FK
Medicare Provider Number
250019
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/14/2019
Participating Start Date
4/1/2019
Participating Approval Date
1/25/2019
Last Recertification Date
8/20/2021
Termination Date
Termination Reason
1/1/2022
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
12261 HIGHWAY 49
STE 11
GULFPORT, MS 39503-2976
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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