Contract Pharmacy Details

WALGREEN CO.
DSH250019 MEMORIAL HOSPITAL AT GULFPORT

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

WALGREEN CO.

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #21286
4500 OLD PASS RD
GULFPORT, MS 39501

Pharmacy Comments

Contract Details

Approval Date

7/8/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Kent Nicaud, President and Chief Executive Officer
(228) 867-4046

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/8/2020

340B Drug Pricing Program Database