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WALGREEN CO
DSH250128C PANOLA MEDICAL CENTER
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Covered Entity Details
Entity Name
PANOLA MEDICAL CENTER
Subdivision Name
PROGRESSIVE MEDICAL MANAGEMENT OF B - Panola Women's and Children's clinic
Type
Disproportionate Share Hospital
340B ID
DSH250128C
Entity Address
255 MEDICAL CENTER DR
PANOLA WOMEN'S AND CHILDREN'S CLINIC
BATESVILLE, MS 38606-8629
Medicare Provider Number
250128
Outpatient Facility Provider Number
Participating Start Date
10/1/2021
Last Recertification Date
8/28/2023
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA; WALGREENS #12308
5148 HWY 51 NORTH
SENATOBIA, MS 38668
Pharmacy Comments
Contract Details
Approval Date
1/7/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Quentin Q Whitwell, CEO
(662) 712-1515
Contract Pharmacy Representative
Panola Medical Center
Chris B Ware, COO
(662) 712-2329
Signed By Date
1/7/2022
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