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VITAL CARE OF MERIDIAN
DSH250069 RUSH FOUNDATION HOSPITAL
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Covered Entity Details
Entity Name
RUSH FOUNDATION HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250069
Entity Address
1314 19TH AVENUE
MERIDIAN, MS 39301
Medicare Provider Number
250069
Participating Start Date
4/1/2008
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
VITAL CARE OF MERIDIAN
Pharmacy Address
1501 23RD AVE
MERIDIAN, MS 39301
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Suzanne Mize, 340B Administrator
(205) 459-9180
Contract Pharmacy Representative
Vital Care
Brad Gilchrist, COO
(601) 482-4003
Signed By Date
4/16/2018
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