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MISSISSIPPI CVS PHARMACY, L.L.C.
DSH250006 BAPTIST MEMORIAL HOSPITAL - UNION COUNTY
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Covered Entity Details
Entity Name
BAPTIST MEMORIAL HOSPITAL - UNION COUNTY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250006
Entity Address
200 STATE HIGHWAY 30 W
NEW ALBANY, MS 38652-3112
Medicare Provider Number
250006
Participating Start Date
9/4/2008
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
MISSISSIPPI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 8273
750 CITY AVE SOUTH
RIPLEY, MS 38663
Pharmacy Comments
Contract Details
Approval Date
7/11/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
WALTER GRACE, CEO AND ADMINISTRATOR
(662) 538-2100
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
7/11/2013
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