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PUBLIX SUPER MARKETS, INC.
DSH420004 MEDICAL UNIVERSITY HOSPITAL AUTHORITY
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Covered Entity Details
Entity Name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Subdivision Name
MEDICAL UNIVERSITY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH420004
Entity Address
169 ASHLEY AVENUE
CHARLESTON, SC 29425
Medicare Provider Number
420004
Participating Start Date
12/1/1992
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS, INC.
Pharmacy Address
PUBLIX PHARMACY #1120
1585 CENTRAL AVENUE, SUITE A
SUMMERVILLE, SC 29483
Pharmacy Comments
Contract Details
Approval Date
7/3/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stephen A. Hargett, CFO
(843) 792-6461
Contract Pharmacy Representative
Publix Super Markets
Fred Ottolino, Vice President of Pharmacy Operations
(863) 688-1188
Signed By Date
7/3/2013
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