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RX4U AT MALBIS
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
RX4U AT MALBIS
Pharmacy Address
29487 STATE HIGHWAY 181
DAPHNE, AL 36526
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
Sim Sokom, Pharmacist in Charge
(251) 279-5455
Signed By Date
4/11/2018
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