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ASCENSION RX 3001
DSH100025 SACRED HEART HEALTH SYSTEM
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Covered Entity Details
Entity Name
SACRED HEART HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100025
Entity Address
5151 NORTH 9TH AVENUE
PENSACOLA, FL 32504
Medicare Provider Number
100025
Participating Start Date
7/1/2003
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
ASCENSION RX 3001
Pharmacy Address
7701 METROPOLIS DR STE 200C
AUSTIN, TX 78744-3125
Pharmacy Comments
Contract Details
Approval Date
7/20/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Susan Cornejo, Chief Operating Officer
(850) 416-6206
Contract Pharmacy Representative
Ascension
Michael young, Pharm Ops
(833) 633-7279
Signed By Date
7/20/2021
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