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PUBLIX SUPER MARKETS, INC.
DSH100017 HALIFAX HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
HALIFAX HEALTH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100017
Entity Address
303 N CLYDE MORRIS BLVD
DAYTONA BEACH, FL 32114
Medicare Provider Number
100017
Participating Start Date
1/1/2009
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS, INC.
Pharmacy Address
PUBLIX PHARMACY #0304
1500 BEVILLE RD STE 300
DAYTONA BEACH, FL 32114
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/4/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
ERIC M. PEBURN, CFO
(386) 425-4568
Contract Pharmacy Representative
publix super markets
ashley tomaskovich, supervisor contract pharmacy
(863) 688-1188 Ext: 53348
Signed By Date
10/15/2018
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