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WAL-MART PHARMACY 10-0176
CAH251337-00 TIPPAH COUNTY HOSPITAL
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Covered Entity Details
Entity Name
TIPPAH COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251337-00
Entity Address
1005 City Ave N
RIPLEY, MS 38663
Medicare Provider Number
251337
Participating Start Date
4/1/2019
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0176
Pharmacy Address
822 CITY AVE SOUTH
RIPLEY, MS 38663
Pharmacy Comments
Contract Details
Approval Date
9/6/2019
Contract Begin Date
9/9/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patrick Chapman, CEO
(662) 837-9221
Contract Pharmacy Representative
Wal-Mart479-___-____
Jodi Prohofsky, Sr. Director Channel Management
(700) 730-9065 Ext: 6
Signed By Date
9/6/2019
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