Contract Pharmacy Details

PUBLIX SUPER MARKETS, INC
DSH110104 CRISP REGIONAL HOSPITAL, INC.

Covered Entity Details

Entity Name

CRISP REGIONAL HOSPITAL, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110104

Entity Address

902 7TH STREET NORTH
CORDELE, GA 31015-5007

Medicare Provider Number

110104

Participating Start Date

1/1/2005

Last Recertification Date

9/9/2024

Pharmacy Details

Pharmacy Name

PUBLIX SUPER MARKETS, INC

Pharmacy Address

PUBLIX PHARMACY #1008
1114 HIGHWAY 96
KATHLEEN, GA 31047

Pharmacy Comments

Contract Details

Approval Date

10/18/2021

Contract Begin Date

1/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/17/2022
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Jessica Carter, CFO
(229) 276-3130

Contract Pharmacy Representative

Publix
Amin Mrugesh, 340B Program Manager
(863) 688-1188 Ext: 52388

Signed By Date

10/18/2021

340B Drug Pricing Program Database