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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
WALGREENS #19297
380 W WOODROW WILSON AVE
JACKSON, MS 39213
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
11/14/2022
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
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