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WALMART PHARMACY 10-5169
DSH250097 SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHWEST MISSISSIPPI REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250097
Entity Address
215 MARION AVE.
MCCOMB, MS 39648-2705
Medicare Provider Number
250097
Participating Start Date
9/9/2005
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
4/14/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robert Cornelius Weathersby, Chief Operating Officer
(601) 249-1882
Contract Pharmacy Representative
Southwest Mississippi Regional Medical Center
Robert Cornelius Weathersby, Chief Operating Officer
(601) 249-1882
Signed By Date
4/14/2023
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