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FAIRVIEW DISCOUNT PHARMACY
CH045770 Southeast Mississippi Rural Health Initiative, Inc.
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Covered Entity Details
Entity Name
Southeast Mississippi Rural Health Initiative, Inc.
Subdivision Name
SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Type
HRSA-Funded Health Center
340B ID
CH045770
Entity Address
5488 U S Highway 49
Hattiesburg, MS 39401-7806
Grant Number
H80CS00610
Participating Start Date
10/1/2002
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
FAIRVIEW DISCOUNT PHARMACY
Pharmacy Address
500 KATIE AVENUE
HATTIESBURG, MS 39401
Pharmacy Comments
Contract Details
Approval Date
4/19/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/2/2018
Ownership change
Contacts
Covered Entity Signing Official
GEROLDEAN DYSE, CEO
(601) 545-8700
Contract Pharmacy Representative
Eric Fromhart, POC
(601) 544-4871
Signed By Date
4/19/2017
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