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ABITACARE LLC
CAH251334-00 CHOCTAW REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
CHOCTAW REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251334-00
Entity Address
8613 MS HWY 12
ACKERMAN, MS 39735
Medicare Provider Number
251334
Participating Start Date
7/1/2015
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
ABITACARE LLC
Pharmacy Address
D/B/A VITAL CARE RX
1501 23RD AVE
SUITE B
MERIDIAN, MS 39301
Pharmacy Comments
Contract Details
Approval Date
1/11/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/23/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jamie Rodgers, CEO
(662) 285-4400
Contract Pharmacy Representative
Vital Care Rx
Brad Gilchrist, COO
(877) 229-1724
Signed By Date
1/11/2019
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