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WAL-MART PHARMACY 10-1074
DSH250099 GREENWOOD LEFLORE HOSPITAL
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Covered Entity Details
Entity Name
GREENWOOD LEFLORE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250099
Entity Address
1401 RIVER ROAD
GREENWOOD, MS 38930
Medicare Provider Number
250099
Participating Start Date
10/1/2001
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1074
Pharmacy Address
1655 SUNSET DR
GRENADA, MS 38901
Pharmacy Comments
Contract Details
Approval Date
10/8/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dawne Holmes, CFO
(662) 459-7119
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/8/2020
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