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HALIFAX HOSPITAL MEDICAL CTR
DSH100017 HALIFAX HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
HALIFAX HEALTH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100017
Entity Address
303 N CLYDE MORRIS BLVD
DAYTONA BEACH, FL 32114
Medicare Provider Number
100017
Participating Start Date
1/1/2009
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
HALIFAX HOSPITAL MEDICAL CTR
Pharmacy Address
PHARMACY
303 N CLYDE MORRIS BLVD
DAYTONA BEACH, FL 32114-2709
Pharmacy Comments
Contract Details
Approval Date
7/8/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/8/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Crystal A Lue, Director, Reimbursement and Revenue
(386) 425-7382
Contract Pharmacy Representative
Halifax Hospital Medical Center
Tarun Verma, 340B/Regulatory Pharmacist
(386) 425-4531
Signed By Date
7/8/2020
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