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MANTACHIE PHARMACY, LLC
CAH251302-00 BOA VIDA HOSPITAL OF ABERDEEN, MS, LLC, D/B/A MONROE REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
BOA VIDA HOSPITAL OF ABERDEEN, MS, LLC, D/B/A MONROE REGIONAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251302-00
Entity Address
400 SOUTH CHESTNUT ST
ABERDEEN, MS 39730
Medicare Provider Number
251302
Participating Start Date
9/24/2010
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
MANTACHIE PHARMACY, LLC
Pharmacy Address
3309 HIGHWAY 371 N
MANTACHIE, MS 38855-7267
Pharmacy Comments
Contract Details
Approval Date
7/13/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chris Chandler, CEO
(662) 369-2455
Contract Pharmacy Representative
Mantachie Pharmacy
katlyn Spradling, Pharmacist
(662) 322-3901
Signed By Date
7/13/2020
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