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BRIOVARX OF FLORIDA, INC
DSH250001 University of Mississippi Medical Center
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Covered Entity Details
Entity Name
University of Mississippi Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250001
Entity Address
2500 NORTH STATE ST.
JACKSON, MS 39216
Medicare Provider Number
250001
Participating Start Date
4/1/1998
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF FLORIDA, INC
Pharmacy Address
D/B/A BRIOVARX OF FLORIDA
9994 PREMIER PKWY
MIRAMAR, FL 33025
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/24/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Grimsley, CFO-Health System
(601) 815-6270
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2019
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