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PUBLIX SUPER MARKET, INC.
DSH100157 LAKELAND REGIONAL MED CTR
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Covered Entity Details
Entity Name
LAKELAND REGIONAL MED CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100157
Entity Address
1324 LAKELAND HILLS BLVD
LAKELAND, FL 33805
Medicare Provider Number
100157
Participating Start Date
1/1/2020
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
PUBLIX SUPER MARKET, INC.
Pharmacy Address
PUBLIX PHARMACY #3211
1324 LAKELAND HILLS BLVD, SUITE 203
LAKELAND, FL 33805
Pharmacy Comments
Contract Details
Approval Date
10/3/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Evan C. Jones, Executive VP & CFO
(863) 687-1062
Contract Pharmacy Representative
Publix Super Markets
Fred Ottolino, Vice President of Pharmacy Operations
(863) 688-1188
Signed By Date
10/3/2013
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