Contract Pharmacy Details

MISSISSIPPI CVS PHARMACY, L.L.C.
DSH250058 SOUTH CENTRAL REGIONAL MEDICAL CENTER

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

MISSISSIPPI CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 05777
501 NORTH 16TH AVE.
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

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/14/2021

340B Drug Pricing Program Database