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JELKS FAMILY PHARMACY
CAH251309-03 FIELD MEMORIAL COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
FIELD MEMORIAL COMMUNITY HOSPITAL
Subdivision Name
GLOSTER CLINIC
Type
Critical Access Hospital
340B ID
CAH251309-03
Entity Address
434 N CAPTAIN GLOSTER DR
GLOSTER, MS 39638
Medicare Provider Number
251309
Outpatient Facility Provider Number
258503
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
JELKS FAMILY PHARMACY
Pharmacy Address
1404 ACADEMY STREET
CENTREVILLE, MS 39631
Pharmacy Comments
Contract Details
Approval Date
1/3/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sherry F Mix, CFO
(601) 890-0546
Contract Pharmacy Representative
Jelks Pharmacy
Ashlee Jelks, Owner
(601) 890-6001
Signed By Date
1/3/2020
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