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LITTLE'S PHARMACY
CAH251300-00 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251300-00
Entity Address
330 N. BROAD ST.
FOREST, MS 39074
Medicare Provider Number
251300
Participating Start Date
1/1/2011
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
LITTLE'S PHARMACY
Pharmacy Address
122 MAIN STREET
RALEIGH, MS 39153-0186
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
12/6/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sydney Sawyer, CEO
(601) 469-4151 Ext: 301
Contract Pharmacy Representative
LITTLE'S PHARMACY
RICHARD A LITTLE, PHARMACIST
(601) 782-4552
Signed By Date
1/14/2019
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