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WALGREEN CO
DSH250128 PANOLA MEDICAL CENTER
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Covered Entity Details
Entity Name
PANOLA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250128
Entity Address
303 MEDICAL CENTER DRIVE
BATESVILLE, MS 38606
Medicare Provider Number
250128
Participating Start Date
7/1/2021
Last Recertification Date
8/31/2022
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
1/14/2022
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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