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MISSISSIPPI CVS PHARMACY, L.L.C.
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
MISSISSIPPI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05923
2424 25TH AVE
GULFPORT, MS 39501
Pharmacy Comments
Contract Details
Approval Date
1/16/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JEFF STEINER, VP OF FINANCE
(228) 865-3076
Contract Pharmacy Representative
CVS Caremark
JACKLYN PARFITT, MANAGER, PAYER RELATIONS
(401) 770-6467
Signed By Date
1/16/2015
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