Contract Pharmacy Details

QUINN PHARMACY
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

QUINN PHARMACY

Pharmacy Address

104 S 13TH AVE
LAUREL, MS 39440

Pharmacy Comments

3/1/10 ADDR CORR (WAS 3150 AUDABON DR.)

Contract Details

Approval Date

7/14/2021

Contract Begin Date

7/21/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/26/2023
Ownership change

Contacts

Covered Entity Signing Official

James T. Canizaro, CFO
(601) 399-6139

Contract Pharmacy Representative

Quinn Pharmacy
Lonnie Hicks, Owner
(601) 428-0688

Signed By Date

7/14/2021