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MISSISSIPPI CVS PHARMACY, L.L.C.
CH04392B MANTACHIE RURAL HEALTH CARE INC
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Covered Entity Details
Entity Name
MANTACHIE RURAL HEALTH CARE INC
Subdivision Name
MANTACHIE RURAL HEALTH CARE, INC. DENTAL
Type
HRSA-Funded Health Center
340B ID
CH04392B
Entity Address
5500 Highway 363
Mantachie, MS 38855-7197
Grant Number
H80CS00096
Participating Start Date
4/1/2016
Last Recertification Date
2/24/2025
Pharmacy Details
Pharmacy Name
MISSISSIPPI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04536
301 AMERICAN AVENUE
BOONEVILLE, MS 38829
Pharmacy Comments
Contract Details
Approval Date
7/22/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MARJORIE MCKINNEY, CEO
(662) 282-4226 Ext: 114
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/22/2020
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