Contract Pharmacy Details

WAL-MART PHARMACY 10-0916
CAH251300-00 INDEPENDENT HEALTHCARE MANAGMENT, INC. D/B/A SE LACKEY MEMORIAL HOSPITAL

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

WAL-MART PHARMACY 10-0916

Pharmacy Address

6072 U.S. HWY. 98
HATTIESBURG, MS 39402

Pharmacy Comments

Contract Details

Approval Date

3/26/2022

Contract Begin Date

3/29/2022

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

sydney sawyer, ceo
(601) 469-4151 Ext: 301

Contract Pharmacy Representative

Walmart
Julie Howard, 340B Program Manager
(479) 277-1498

Signed By Date

3/26/2022

340B Drug Pricing Program Database