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GENOA HEALTHCARE LLC
RRC250009-00 MAGNOLIA REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
MAGNOLIA REGIONAL HEALTH CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC250009-00
Entity Address
611 ALCORN DRIVE
CORINTH, MS 38834
Medicare Provider Number
250009
Participating Start Date
4/1/2017
Last Recertification Date
8/15/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
8791 NORTHWEST DR
SOUTHAVEN, MS 38671
Pharmacy Comments
Contract Details
Approval Date
1/17/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Stephen Ray Thames, CFO
(662) 293-7647
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/17/2025
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