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WAL-MART PHARMACY 10-0239
CAH251312-00 TYLER HOLMES MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
TYLER HOLMES MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251312-00
Entity Address
409 Tyler Holmes Drive
WINONA, MS 38967
Medicare Provider Number
251312
Participating Start Date
1/1/2018
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0239
Pharmacy Address
220 VETERANS MEMORIAL DRIVE
KOSCIUSKO, MS 39090
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cori H Bailey, Administrator
(662) 283-4114 Ext: 6126
Contract Pharmacy Representative
Walmart
Christian Nava, Senior Manager, Program Development-340B
(210) 632-0647
Signed By Date
10/15/2024
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