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T D 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
T D PHARMACY
Pharmacy Address
T-D PHARMACY, INC.
12372 HIGHWAY 49
GULFPORT, MS 39503-2741
Pharmacy Comments
Contract Details
Approval Date
4/30/2012
Contract Begin Date
4/30/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2020
Ownership change
Contacts
Covered Entity Signing Official
Jennifer Dumal, Vice President Patient Care Services
(228) 297-9221
Contract Pharmacy Representative
Dan Day, Owner
(228) 832-1414
Signed By Date
4/16/2012
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