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JACKSONS DISCOUNT PHARMACY
DSH250019 MEMORIAL HOSPITAL AT GULFPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250019
Entity Address
4500 Thirteenth Street
GULFPORT, MS 39501
Medicare Provider Number
250019
Participating Start Date
7/1/2000
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
JACKSONS DISCOUNT PHARMACY
Pharmacy Address
11340 THREE RIVERS RD STE A
GULFPORT, MS 39503-3650
Pharmacy Comments
Contract Details
Approval Date
4/30/2012
Contract Begin Date
4/30/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jennifer Dumal, Vice President Patient Care Services
(228) 297-9221
Contract Pharmacy Representative
Gary Jackson, Owner
(228) 832-8000
Signed By Date
4/16/2012
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