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WALGREEN CO.
DSH250019 MEMORIAL HOSPITAL AT GULFPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL AT GULFPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250019
Entity Address
4500 Thirteenth Street
GULFPORT, MS 39501
Medicare Provider Number
250019
Participating Start Date
7/1/2000
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS #17035
4031 POPPS FERRY RD STE A
DIBERVILLE, MS 39540
Pharmacy Comments
Contract Details
Approval Date
4/13/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/12/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
JEFF STEINER, VP OF FINANCE
(228) 865-3076
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/13/2018
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