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WAL-MART PHARMACY 10-5419
DSH250172 Tate County Hospital
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Covered Entity Details
Entity Name
Tate County Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250172
Entity Address
401 GETWELL DRIVE
SENATOBIA, MS 38668
Medicare Provider Number
250172
Participating Start Date
7/1/2024
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5419
Pharmacy Address
2600 MCINGVALE ROAD
HERNANDO, MS 38632
Pharmacy Comments
Contract Details
Approval Date
4/12/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/28/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joshua Lloyd Hammons, CEO
(662) 612-0311
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/12/2024
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