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THOMAS PHARMACY PINE TREE VILLAGE
DSH250058 SOUTH CENTRAL REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTH CENTRAL REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250058
Entity Address
1220 JEFFERSON STREET
LAUREL, MS 39440
Medicare Provider Number
250058
Participating Start Date
7/1/2004
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
THOMAS PHARMACY PINE TREE VILLAGE
Pharmacy Address
THOMAS PHARMACY
2341 HIGHWAY 15 N
PO BOX 4111
LAUREL, MS 39440
Pharmacy Comments
Contract Details
Approval Date
7/14/2021
Contract Begin Date
7/21/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James T. Canizaro, CFO
(601) 399-6139
Contract Pharmacy Representative
Thomas Pharmacy
Stephanie M Lovett, Pharmacist
(601) 518-3590 Ext: 202
Signed By Date
7/14/2021
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