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NOBLE HEALTH SERVICES INC.
CAH251300-00 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251300-00
Entity Address
330 N. BROAD ST.
FOREST, MS 39074
Medicare Provider Number
251300
Participating Start Date
1/1/2011
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
NOBLE HEALTH SERVICES INC.
Pharmacy Address
6040 TARBELL ROAD
SYRACUSE, NY 13206
Pharmacy Comments
Contract Details
Approval Date
3/10/2022
Contract Begin Date
3/11/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
sydney sawyer, ceo
(601) 469-4151 Ext: 301
Contract Pharmacy Representative
KPH Healthcare Services, Inc.
Debbi Barber, 340B Program Director
(315) 287-3600 Ext: 2423
Signed By Date
3/10/2022
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