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PUBLIX SUPER MARKETS
DSH420004 MEDICAL UNIVERSITY HOSPITAL AUTHORITY
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Covered Entity Details
Entity Name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Subdivision Name
MEDICAL UNIVERSITY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH420004
Entity Address
169 ASHLEY AVENUE
CHARLESTON, SC 29425
Medicare Provider Number
420004
Participating Start Date
12/1/1992
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS
Pharmacy Address
PUBLIX PHARMACY #0671
2125 EAST CR 540-A
LAKELAND, FL 33813
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
7/31/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew J Wain, COO
(843) 792-8533
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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