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MISSISSIPPI CVS PHARMACY, L.L.C.
DSH250167 METHODIST H/C OLIVE BRANCH HOSPT
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Covered Entity Details
Entity Name
METHODIST H/C OLIVE BRANCH HOSPT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250167
Entity Address
4250 BETHEL ROAD
OLIVE BRANCH, MS 38654
Medicare Provider Number
250167
Participating Start Date
4/1/2019
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
MISSISSIPPI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08955
55 GOODMAN ROAD WEST
SOUTHAVEN, MS 38671
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chuck Lane, SVP/Associate CFO
(901) 516-0549
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/15/2020
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