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PUBLIX SUPER MARKETS INC
DSH100093 BAPTIST HOSPITAL
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Covered Entity Details
Entity Name
BAPTIST HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100093
Entity Address
123 Baptist Way
PENSACOLA, FL 32503
Medicare Provider Number
100093
Participating Start Date
4/1/2009
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS INC
Pharmacy Address
PUBLIX PHARMACY #0801
2250 SOUTH FERDON BOULEVARD
CRESTVIEW, FL 32536
Pharmacy Comments
Contract Details
Approval Date
4/17/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/20/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Andrew L. Terry, Vice President Revenue Management
(850) 469-7643
Contract Pharmacy Representative
Publix
Kimberly Bone, Manager of Managed Care, Pharmacy Operations
(863) 688-1188 Ext: 52364
Signed By Date
4/17/2019
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