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WAL-MART PHARMACY 10-1468
DSH250128 PANOLA MEDICAL CENTER
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Covered Entity Details
Entity Name
PANOLA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250128
Entity Address
303 MEDICAL CENTER DRIVE
BATESVILLE, MS 38606
Medicare Provider Number
250128
Participating Start Date
7/1/2021
Last Recertification Date
8/31/2022
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1468
Pharmacy Address
205 HOUSE-CARLSON DRIVE
BATESVILLE, MS 38606
Pharmacy Comments
Contract Details
Approval Date
7/20/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tim Brown, Chief Financial Officer
(865) 888-9359
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/16/2018
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