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WINN DIXIE MONTGOMERY, LLC.
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
WINN DIXIE MONTGOMERY, LLC.
Pharmacy Address
WINN-DIXIE PHARMACY #495
5975 MOBILE HWY
PENSACOLA, FL 32526
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/28/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Andrew L. Terry, Vice President Revenue Management
(850) 469-7643
Contract Pharmacy Representative
Southeastern Grociers
David Chism, Seinior Director
(904) 370-6455 Ext: 9043706455
Signed By Date
10/14/2019
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