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WAL-MART PHARMACY 10-2715
DSH250123 SINGING RIVER GULFPORT
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Covered Entity Details
Entity Name
SINGING RIVER GULFPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250123
Entity Address
15200 COMMUNITY ROAD
GULFPORT, MS 39503-5307
Medicare Provider Number
250123
Participating Start Date
3/11/2022
Last Recertification Date
8/28/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2715
Pharmacy Address
3615 SANGANI BLVD.
D'IBERVILLE, MS 39540
Pharmacy Comments
Contract Details
Approval Date
1/15/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Heath Allen Thompson, Administrator Ancillary Services
(228) 818-1191
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2024
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