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TH RX4U
DSH010113 MOBILE INFIRMARY MEDICAL CENTER
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Covered Entity Details
Entity Name
MOBILE INFIRMARY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010113
Entity Address
FIVE MOBILE INFIRMARY CIRCLE
MOBILE, AL 36607
Medicare Provider Number
010113
Participating Start Date
1/1/2018
Last Recertification Date
9/7/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
TH RX4U
Pharmacy Address
750 MORPHY AVE
FAIRHOPE, AL 36532
Pharmacy Comments
Contract Details
Approval Date
4/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lee Ann Cain, Vice President
(251) 279-1510
Contract Pharmacy Representative
Gulf Health Management Services
Sara Nolan, Pharmacist In Charge
(251) 279-2255
Signed By Date
4/11/2018
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