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PUBLIX SUPER MARKETS, INC.
PED103301-00 Nicklaus Children's Hospital
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Covered Entity Details
Entity Name
Nicklaus Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED103301-00
Entity Address
3100 SW 62nd Avenue
Miami, FL 33155
Medicare Provider Number
103301
Participating Start Date
10/1/2011
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS, INC.
Pharmacy Address
PUBLIX PHARMACY #3215
3100 SW 62ND AVENUE
MIAMI, FL 33155
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jose Perdomo, Interim President and COO
(305) 666-6511 Ext: 2010
Contract Pharmacy Representative
Publix
Kimberly Bone, Manager of Managed Care, Pharmacy Operations
(863) 688-1188 Ext: 52364
Signed By Date
7/15/2019
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