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WAL-MART PHARMACY 10-0273
CH04392B MANTACHIE RURAL HEALTH CARE INC
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Covered Entity Details
Entity Name
MANTACHIE RURAL HEALTH CARE INC
Subdivision Name
MANTACHIE RURAL HEALTH CARE, INC. DENTAL
Type
HRSA-Funded Health Center
340B ID
CH04392B
Entity Address
5500 Highway 363
Mantachie, MS 38855-7197
Grant Number
H80CS00096
Participating Start Date
4/1/2016
Last Recertification Date
2/24/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0273
Pharmacy Address
100 INTERCHANGE DRIVE
FULTON, MS 38843
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MARJORIE MCKINNEY, CEO
(662) 282-4226 Ext: 114
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2019
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