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ABITACARE LLC
DSH250099 GREENWOOD LEFLORE HOSPITAL
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Covered Entity Details
Entity Name
GREENWOOD LEFLORE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250099
Entity Address
1401 RIVER ROAD
GREENWOOD, MS 38930
Medicare Provider Number
250099
Participating Start Date
10/1/2001
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
ABITACARE LLC
Pharmacy Address
D/B/A VITAL CARE RX
1501 23RD AVE
SUITE B
MERIDIAN, MS 39301
Pharmacy Comments
Contract Details
Approval Date
7/14/2022
Contract Begin Date
7/19/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dawne Holmes, CFO
(662) 459-7119
Contract Pharmacy Representative
Vital Care Rx
Brad Gilchrist, COO
(877) 229-1724
Signed By Date
7/14/2022
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