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PAVILION PLAZA PHARMACY
DSH100088 BAPTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
BAPTIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100088
Entity Address
800 PRUDENTIAL DRIVE
JACKSONVILLE, FL 32207
Medicare Provider Number
100088
Participating Start Date
7/1/2006
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PAVILION PLAZA PHARMACY
Pharmacy Address
BAPTIST PHARMACY LANE
810 LANE AVE S
JACKSONVILLE, FL 32205
Pharmacy Comments
Contract Details
Approval Date
3/23/2012
Contract Begin Date
3/23/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Lukaszewski, Chief Financial Officer
(904) 202-2852
Contract Pharmacy Representative
Janice Rogers, Pharmacy Director
(904) 202-2852
Signed By Date
3/15/2012
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