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PHARMACY OF TAMPA, INC
DSH450176 MISSION HOSPITAL
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Covered Entity Details
Entity Name
MISSION HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450176
Entity Address
900 SOUTH BRYAN
MISSION, TX 78572
Medicare Provider Number
450176
Participating Start Date
10/1/2016
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
PHARMACY OF TAMPA, INC
Pharmacy Address
D.B.A HOPE AND PACIFIC PHARMACY
4433 GUNN HWY
TAMPA, FL 33618-3361
Pharmacy Comments
Contract Details
Approval Date
7/25/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/4/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kennetha Foster, Chief Nursing Officer
(956) 323-9108
Contract Pharmacy Representative
Independent Medical Group, LLC
Clifford W. Knights, CEO
(786) 523-2562
Signed By Date
7/25/2018
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