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WAL-MART PHARMACY 10-1025
CH04578B AMITE COUNTY MEDICAL SERVICES, INC.
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Covered Entity Details
Entity Name
AMITE COUNTY MEDICAL SERVICES, INC.
Subdivision Name
LIBERTY DENTAL SERVICES
Type
HRSA-Funded Health Center
340B ID
CH04578B
Entity Address
102 FREEDOM DRIVE
LIBERTY, MS 39645-0302
Grant Number
H80CS00609
Participating Start Date
7/1/2016
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1025
Pharmacy Address
1608 VETERANS BLVD
MCCOMB, MS 39648
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
Pam T. Poole, Executive Director
(601) 657-4326 Ext: 126
Contract Pharmacy Representative
Amite County Medical Services, Inc.
Pam T. Poole, Executive Director
(601) 657-4326 Ext: 126
Signed By Date
1/15/2020
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