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PUBLIX PHARMACY #0425
DSH100052 WINTER HAVEN HOSPITAL
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Covered Entity Details
Entity Name
WINTER HAVEN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100052
Entity Address
200 AVENUE F, NE
WINTER HAVEN, FL 33881
Medicare Provider Number
100052
Participating Start Date
1/1/2008
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY #0425
Pharmacy Address
1090 SPIRIT LAKE ROAD
WINTER HAVEN, FL 33880
Pharmacy Comments
Contract Details
Approval Date
7/14/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/5/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carl Tremonti, Chief Financial Officer
(813) 870-4020
Contract Pharmacy Representative
Publix
Jacqueline Rusch, Manager of Managed Care
(863) 688-1188 Ext: 52364
Signed By Date
7/14/2017
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