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PUBLIX PHARMACY #0524
DSH100173 AdventHealth TAMPA
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Covered Entity Details
Entity Name
AdventHealth TAMPA
Subdivision Name
University Community dba Florida Hospital Tampa
Type
Disproportionate Share Hospital
340B ID
DSH100173
Entity Address
3100 East FLETCHER Avenue
TAMPA, FL 33613
Medicare Provider Number
100173
Participating Start Date
1/1/2017
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY #0524
Pharmacy Address
3939 VAN DYKE ROAD
LUTZ, FL 33558
Pharmacy Comments
Contract Details
Approval Date
1/11/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tyson Davis, Chief Financial Officer
(813) 615-7159
Contract Pharmacy Representative
Publix
Dain Rusk, Vice President
(863) 688-1188
Signed By Date
1/11/2023
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