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PUBLIX PHARMACY #1530
SCH100090-00 FLAGLER HOSPITAL
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Covered Entity Details
Entity Name
FLAGLER HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH100090-00
Entity Address
400 HEALTH PARK BLVD
ST AUGUSTINE, FL 32086
Medicare Provider Number
100090
Participating Start Date
7/1/2018
Last Recertification Date
9/23/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY #1530
Pharmacy Address
4255 US HWY 1 S STE 1
ST AUGUSTINE, FL 32086
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Murray Sherwood Marsh, Jr., Chief Financial Officer
(904) 819-4400
Contract Pharmacy Representative
Publix
Kimberly Bone, Manager of Managed Care, Pharmacy Operations
(863) 688-1188 Ext: 52364
Signed By Date
1/15/2019
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