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WALMART PHARMACY 10-4619
DSH250004 NORTH MISSISSIPPI MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH MISSISSIPPI MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250004
Entity Address
830 SOUTH GLOSTER ST
TUPELO, MS 38801
Medicare Provider Number
250004
Participating Start Date
1/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-4619
Pharmacy Address
316 S. GLOSTER STREET
TUPELO, MS 38801
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
7/29/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BRUCE J. TOPPIN, GENERAL COUNSEL, PRIVACY OFFICER & COPORATE SECRETARY
(662) 377-4229
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2020
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