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WOOLMARKET PHARMACY
DSH250019 MEMORIAL HOSPITAL AT GULFPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250019
Entity Address
4500 Thirteenth Street
GULFPORT, MS 39501
Medicare Provider Number
250019
Participating Start Date
7/1/2000
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WOOLMARKET PHARMACY
Pharmacy Address
13034 SHRINERS BLVD STE A
BILOXI, MS 39532-8250
Pharmacy Comments
Contract Details
Approval Date
7/19/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Contract Pharmacy Representative
Woolmarket Pharmacy
Casey Mino, Owner
(228) 392-5355
Signed By Date
7/19/2019
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