Contract Pharmacy Details

WINN DIXIE PHARMACY #1513
DSH250123 SINGING RIVER GULFPORT

Covered Entity Details

Entity Name

SINGING RIVER GULFPORT

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH250123

Entity Address

15200 COMMUNITY ROAD
GULFPORT, MS 39503-5307

Medicare Provider Number

250123

Participating Start Date

3/11/2022

Last Recertification Date

8/28/2024

Entity Termination Date

4/1/2025

Pharmacy Details

Pharmacy Name

WINN DIXIE PHARMACY #1513

Pharmacy Address

10511 D'IBERVILLE BLVD
D'IBERVILLE, MS 39540

Pharmacy Comments

Contract Details

Approval Date

4/15/2022

Contract Begin Date

7/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/13/2023
Pharmacy closed

Contacts

Covered Entity Signing Official

Heath Allen Thompson, Administrator Ancillary Services
(228) 818-1191

Contract Pharmacy Representative

Southeastern Grocers LLC
Michael LeBlanc, Sr.Director, Pharmacy
(904) 783-5897

Signed By Date

4/15/2022

340B Drug Pricing Program Database