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ELIXIR PHARMACY, LLC
DSH250078 FORREST GENERAL HOSPITAL
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Covered Entity Details
Entity Name
FORREST GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250078
Entity Address
6051 U.S. HIGHWAY 49
HATTIESBURG, MS 39401
Medicare Provider Number
250078
Participating Start Date
7/1/2002
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
ELIXIR PHARMACY, LLC
Pharmacy Address
7835 FREEDOM AVE NW
NORTH CANTON, OH 44720
Pharmacy Comments
Contract Details
Approval Date
10/13/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/20/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ben Hester, CFO
(601) 288-4225
Contract Pharmacy Representative
Elixir Pharmacy LLC
Bill Trexler, Vice President Finance
(877) 437-9012
Signed By Date
10/13/2022
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