340B Drug Pricing Program Database
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PUBLIX SUPER MARKETS, INC.
DSH110104 CRISP REGIONAL HOSPITAL, INC.
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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 #1263
5451 BOWMAN RD
MACON, GA 31210
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
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