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PUBLIX SUPER MARKETS, INC.
DSH100075 ST JOSEPH'S HOSPITAL
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Covered Entity Details
Entity Name
ST JOSEPH'S HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100075
Entity Address
3001 WEST DR. M L KING JR BLVD
TAMPA, FL 33607
Medicare Provider Number
100075
Participating Start Date
4/1/2003
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKETS, INC.
Pharmacy Address
PUBLIX COMPOUNDING PHARMACY #3212
2424 ORLANDO CENTRAL PKWY STE 200
ORLANDO, FL 32809
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
4/1/2019
Pharmacy closed
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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