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MISSISSIPPI CVS PHARMACY, L.L.C.
DSH250069 RUSH FOUNDATION HOSPITAL
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Covered Entity Details
Entity Name
RUSH FOUNDATION HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250069
Entity Address
1314 19TH AVENUE
MERIDIAN, MS 39301
Medicare Provider Number
250069
Participating Start Date
4/1/2008
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
MISSISSIPPI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05846
822 HWY 35 N
FOREST, MS 39074
Pharmacy Comments
Contract Details
Approval Date
10/14/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/19/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Chuck Reece, COO
(601) 483-0011
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
10/14/2013
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