Contract Pharmacy Details

PROCARE PHARMACY, L.L.C.
DSH250004 NORTH MISSISSIPPI MEDICAL CENTER

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

PROCARE PHARMACY, L.L.C.

Pharmacy Address

CVS/PHARMACY #10994
60 MARKET CENTER DRIVE
SUITE 103
COLLIERVILLE, TN 38017

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

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/15/2020

340B Drug Pricing Program Database