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PUBLIX SUPER MARKETS, INC.
DSH100285 MEMORIAL HOSPITAL MIRAMAR
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL MIRAMAR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100285
Entity Address
1901 SW 172ND AVENUE
Miramar, FL 33029
Medicare Provider Number
100285
Participating Start Date
10/1/2006
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS, INC.
Pharmacy Address
PUBLIX PHARMACY #1301
10018 GRIFFIN RD.
COOPER CITY, FL 33328
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/28/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOSEPH STUCZYNSKI, CEO
(954) 844-6871
Contract Pharmacy Representative
Publix
Amin Mrugesh, 340B Program Manager
(863) 688-1188 Ext: 52388
Signed By Date
1/17/2023
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