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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #21286
4500 OLD PASS RD
GULFPORT, MS 39501
Pharmacy Comments
Contract Details
Approval Date
10/17/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/8/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
JEFF STEINER, VP OF FINANCE
(228) 865-3076
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/17/2014
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