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MITCHELL'S PARK STREET PHCY
CAH041306-00 IZARD REGIONAL HOSPITAL, LLC
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Covered Entity Details
Entity Name
IZARD REGIONAL HOSPITAL, LLC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH041306-00
Entity Address
61 GRASSE ST
CALICO ROCK, AR 72519
Medicare Provider Number
041306
Participating Start Date
4/1/2023
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
MITCHELL'S PARK STREET PHCY
Pharmacy Address
526 PARK ST
P.O. BOX 569
CALICO ROCK, AR 72519-9070
Pharmacy Comments
Contract Details
Approval Date
3/13/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kim Skidmore, Hospital Administrator
(870) 297-8400
Contract Pharmacy Representative
Mitchell's Park Street Pharmacy
Steven Mitchell, Owner
(870) 297-8107
Signed By Date
1/17/2023
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