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PUBLIX TENNESSEE, LLC
DSH440073 MAURY REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MAURY REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440073
Entity Address
1224 TROTWOOD AVENUE
COLUMBIA, TN 38401
Medicare Provider Number
440073
Participating Start Date
7/20/2022
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
PUBLIX TENNESSEE, LLC
Pharmacy Address
PUBLIX PHARMACY #1047
4935 MAIN STREET
SPRING HILL, TN 37174-9242
Pharmacy Comments
Contract Details
Approval Date
9/29/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Martin Chaney, Chief Executive Officer
(931) 380-4008
Contract Pharmacy Representative
Publix Super Markets
Jacqueline Rush, Manager of Managed Care, Pharmacy Operations
(863) 688-1188 Ext: 52364
Signed By Date
9/29/2022
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