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WALLACE DRUG COMPANY INC
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
WALLACE DRUG COMPANY INC
Pharmacy Address
520 N MAGNOLIA ST
LAUREL, MS 39440-3559
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
Wallace Drugs
Joe Robertson, Owner
(601) 428-1277
Signed By Date
7/14/2021
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