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WINN-DIXIE PHARMACY
DSH250019 MEMORIAL HOSPITAL AT GULFPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250019
Entity Address
4500 Thirteenth Street
GULFPORT, MS 39501
Medicare Provider Number
250019
Participating Start Date
7/1/2000
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WINN-DIXIE PHARMACY
Pharmacy Address
DBA WINN-DIXIE PHARMACY #1479
109 NORTH CLEVELAND AVE
LONG BEACH, MS 39560
Pharmacy Comments
Contract Details
Approval Date
1/3/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/13/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Contract Pharmacy Representative
Southeastern Grociers
David Chism, Seinior Director
(904) 370-6455 Ext: 9043706455
Signed By Date
1/3/2019
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