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WINN DIXIE STORES, INC.
DSH100142 JACKSON HOSPITAL
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Covered Entity Details
Entity Name
JACKSON HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100142
Entity Address
4250 HOSPITAL DRIVE
MARIANNA, FL 32446
Medicare Provider Number
100142
Participating Start Date
4/1/2010
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WINN DIXIE STORES, INC.
Pharmacy Address
WINN-DIXIE PHARMACY #555
4478 MARKET STREET
MARIANNA, FL 32446
Pharmacy Comments
Contract Details
Approval Date
10/15/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/11/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
LARRY MEESE, CEO
(850) 718-2622
Contract Pharmacy Representative
Curtis Hartin, Director of Pharmacy
(904) 370-7776
Signed By Date
10/15/2013
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