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WAL-MART PHARMACY 10-0239
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
WAL-MART PHARMACY 10-0239
Pharmacy Address
220 VETERANS MEMORIAL DRIVE
KOSCIUSKO, MS 39090
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Grimsley, CFO-Health System
(601) 815-6270
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2019
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