Contract Pharmacy Details

WALGREEN CO.
DSH250001 University of Mississippi Medical Center

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

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 07184
2896 MCDOWELL ROAD EXTENSION
JACKSON, MS 39204-4238

Pharmacy Comments

Contract Details

Approval Date

1/15/2019

Contract Begin Date

4/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/17/2025
Pharmacy closed

Contacts

Covered Entity Signing Official

Jeffrey Grimsley, CFO-Health System
(601) 815-6270

Contract Pharmacy Representative

Walgreens
Blake Hartgraves, Health Systems Account Manager
(972) 322-3581

Signed By Date

1/15/2019

340B Drug Pricing Program Database