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PUBLIX SUPER MARKETS, INC.
RRC100307-00 ST. VINCENTS MEDICAL CENTER SOUTHSID
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Covered Entity Details
Entity Name
ST. VINCENTS MEDICAL CENTER SOUTHSID
Subdivision Name
Type
Rural Referral Center
340B ID
RRC100307-00
Entity Address
4201 BELFORT ROAD
JACKSONVILLE, FL 32216
Medicare Provider Number
100307
Participating Start Date
10/1/2020
Last Recertification Date
8/20/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS, INC.
Pharmacy Address
PUBLIX PHARMACY #1468
2771 MONUMENT RD., STE 19
JACKSONVILLE, FL 32225
Pharmacy Comments
Contract Details
Approval Date
1/24/2022
Contract Begin Date
1/24/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/9/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Susan Cornejo, Chief Operating Officer
(850) 416-6206
Contract Pharmacy Representative
Publix Super Markets
Dain Rusk, Vice President Pharmacy
(863) 616-5846
Signed By Date
1/24/2022
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