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MISSISSIPPI CVS PHARMACY, L.L.C.
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
MISSISSIPPI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05740
1701 A HWY 43 N
PICAYUNE, MS 39466
Pharmacy Comments
Contract Details
Approval Date
1/13/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/13/2021
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