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PUBLIX SUPER MARKETS, INC.
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, INC.
Pharmacy Address
PUBLIX CENTRAL PHARMACY #3201
2424 ORLANDO CENTRAL PARKWAY
ORLANDO, FL 32809
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
12/31/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Matthew J Wain, COO
(843) 792-8533
Contract Pharmacy Representative
Medical University Hospital Authority
Jason Mills, Pharmacy Manager
(843) 792-7354
Signed By Date
1/15/2019
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