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PRINCE PHARMACY
DSH040067 MAGNOLIA REGIONAL HEALTH SYSTEM INC D/B/A MAGNOLIA REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MAGNOLIA REGIONAL HEALTH SYSTEM INC D/B/A MAGNOLIA REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040067
Entity Address
101 HOSPITAL DRIVE
MAGNOLIA, AR 71753
Medicare Provider Number
040067
Participating Start Date
10/1/2016
Last Recertification Date
8/15/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
PRINCE PHARMACY
Pharmacy Address
PRINCE PHARMACY
211 E STADIUM
MAGNOLIA, AR 71753-2032
Pharmacy Comments
Contract Details
Approval Date
10/14/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Margaret West, CEO
(870) 235-3211
Contract Pharmacy Representative
Prince Pharmacy
Jeff Prince, Owner
(870) 234-7292
Signed By Date
10/14/2016
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