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KROGER PHARMACY #493
DSH250001 University of Mississippi Medical Center
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Covered Entity Details
Entity Name
University of Mississippi Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250001
Entity Address
2500 NORTH STATE ST.
JACKSON, MS 39216
Medicare Provider Number
250001
Participating Start Date
4/1/1998
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #493
Pharmacy Address
1070 SPILLWAY CIRCLE
BRANDON, MS 39047-6035
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeffrey Grimsley, CFO-Health System
(601) 815-6270
Contract Pharmacy Representative
Kroger
Niema Washington, Contract Manager
(513) 582-0435
Signed By Date
10/15/2018
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