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WALGREEN CO
CAH251326-00 Jefferson Davis Community Hospital
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Covered Entity Details
Entity Name
Jefferson Davis Community Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251326-00
Entity Address
1102 Rose Street
Prentiss, MS 39474
Medicare Provider Number
251326
Participating Start Date
4/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #10805
1628 SIMPSON HWY 49
MAGEE, MS 39111-5000
Pharmacy Comments
Contract Details
Approval Date
10/2/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bryan Keith Maxie, Regional Administrator
(601) 297-0503
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/2/2022
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