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PUBLIX SUPER MARKETS
DSH100157 LAKELAND REGIONAL MED CTR
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Covered Entity Details
Entity Name
LAKELAND REGIONAL MED CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100157
Entity Address
1324 LAKELAND HILLS BLVD
LAKELAND, FL 33805
Medicare Provider Number
100157
Participating Start Date
1/1/2020
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS
Pharmacy Address
PUBLIX PHARMACY #0671
2125 EAST CR 540-A
LAKELAND, FL 33813
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/28/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lance Green, EVP/Chief Financial Officer
(863) 687-1100 Ext: 5225
Contract Pharmacy Representative
Publix
Jacqueline Rusch, Manager of Managed Care
(863) 688-1188 Ext: 52364
Signed By Date
4/13/2020
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