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THE CORNER DRUG STORE
DSH250019 MEMORIAL HOSPITAL AT GULFPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250019
Entity Address
4500 Thirteenth Street
GULFPORT, MS 39501
Medicare Provider Number
250019
Participating Start Date
7/1/2000
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
THE CORNER DRUG STORE
Pharmacy Address
5101 BEATLINE RD
LONG BEACH, MS 39560
Pharmacy Comments
Contract Details
Approval Date
10/12/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kent Nicaud, President and Chief Executive Officer
(228) 867-4046
Contract Pharmacy Representative
TD Pharmacy
Stephen Pisarich, Owner
(228) 832-1414
Signed By Date
10/12/2022
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