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WINN DIXIE PHARMACY#2626
CH045770 Southeast Mississippi Rural Health Initiative, Inc.
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Covered Entity Details
Entity Name
Southeast Mississippi Rural Health Initiative, Inc.
Subdivision Name
SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Type
HRSA-Funded Health Center
340B ID
CH045770
Entity Address
5488 U S Highway 49
Hattiesburg, MS 39401-7806
Grant Number
H80CS00610
Participating Start Date
10/1/2002
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
WINN DIXIE PHARMACY#2626
Pharmacy Address
4400 HARDY ST
HATTIESBURG, MS 39402-1372
Pharmacy Comments
Contract Details
Approval Date
12/16/2020
Contract Begin Date
12/16/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
GEROLDEAN DYSE, CEO
(601) 545-8700
Contract Pharmacy Representative
Southeastern Grociers
David Chism, Seinior Director
(904) 370-6455 Ext: 9043706455
Signed By Date
12/16/2020
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