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LIBERTY DRUG STORE
CAH251309-00 FIELD MEMORIAL COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
FIELD MEMORIAL COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251309-00
Entity Address
178 HWY 24
CENTREVILLE, MS 39631-4171
Medicare Provider Number
251309
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
LIBERTY DRUG STORE
Pharmacy Address
P.O. BOX 217
110 MAIN STREET
LIBERTY, MS 39645
Pharmacy Comments
Contract Details
Approval Date
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHAD NETTERVILLE, CEO
(601) 890-0545
Contract Pharmacy Representative
Liberty
Ron Blalock, Owner
(601) 657-8051
Signed By Date
10/14/2020
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