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ELIXIR PHARMACY, LLC
CAH251324-00 WALTHALL GENERAL HOSPITAL
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Covered Entity Details
Entity Name
WALTHALL GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251324-00
Entity Address
100 HOSPITAL DRIVE
TYLERTOWN, MS 39667-2022
Medicare Provider Number
251324
Participating Start Date
10/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
ELIXIR PHARMACY, LLC
Pharmacy Address
7835 FREEDOM AVE NW
NORTH CANTON, OH 44720
Pharmacy Comments
Contract Details
Approval Date
10/14/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bryan Keith Maxie, Regional Administrator
(601) 297-0503
Contract Pharmacy Representative
Elixir Pharmacy LLC
Bill Trexler, Vice President Finance
(877) 437-9012
Signed By Date
10/14/2022
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