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PUBLIX PHARMACY #0446
DSH100017 HALIFAX HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
HALIFAX HEALTH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100017
Entity Address
303 N CLYDE MORRIS BLVD
DAYTONA BEACH, FL 32114
Medicare Provider Number
100017
Participating Start Date
1/1/2009
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PUBLIX PHARMACY #0446
Pharmacy Address
1478 W GRANADA BLVD
ORMOND BEACH, FL 32174
Pharmacy Comments
Contract Details
Approval Date
4/4/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/12/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ERIC PEBURN, CFO
(386) 425-4568
Contract Pharmacy Representative
Publix Super Markets
Fred Ottolino, Vice President of Pharmacy Operations
(863) 688-1188
Signed By Date
4/4/2013
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