Contract Pharmacy Details

GOLDEN PHARMACY INC
DSH100142 JACKSON HOSPITAL

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

GOLDEN PHARMACY INC

Pharmacy Address

17324 MAIN ST N
BLOUNTSTOWN, FL 32424

Pharmacy Comments

Contract Details

Approval Date

1/9/2014

Contract Begin Date

4/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/15/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

LARRY MEESE, CEO
(850) 718-2622

Contract Pharmacy Representative

Clifford Goodman, President
(850) 674-4557

Signed By Date

1/9/2014